Publication of the Proceedings of the 16th APPAC 2011

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Medimond - Monduzzi Editore International Proceedings Division
Selected Paper from
16th APPAC
international Conference
May 17-20, 2011
Athens (Greece)
MEDIMOND
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Index
Early Signs of Autism in Infancy A Retrospective Clinical Study
Alonim H..............................................................................................................................................................
1
Addressing the childhood obesity epidemic: The Healthy Bodies and Healthy
Minds project.
Bateman H., Duncham H., Maxwell L. .............................................................................................................
5
Use of Internet and online interactions in a Brazilian sample
Ferreira P.P., Bolsoni-Silva A.T........................................................................................................................
11
Passive Client Representation Hinders Vision Rehabilitation Professionals
effectiveness
Cordella B., Greco F., Grasso M. .....................................................................................................................
15
WhatsOnWeb: A Sonificated Search Engine for Blind People
Mele M.L., Federici S., Borsci S. ......................................................................................................................
25
Homophobia and Disability: Literature Review
Meloni F., Federici S., Mele M.L. ......................................................................................................................
31
Attitudes and Perceptions of General Population towards mental illness;
drawing future mental health services
Panayiotopoulos C., Pavlakis A.......................................................................................................................
37
Autonomic Nervous System reactivity, emotion and stress response in
psychopathology.
Pruneti C., Cosentin C., Fontana F..................................................................................................................
43
Selected treatment strategies for emotional and behavioural disorders in children
and adolescents
Samuel E. ............................................................................................................................................................
© Medimond
III
49
© Medimond
IV
16th APPAC International Conference (May 17-20, 2011, Athens, Greece)
Early Signs of Autism in Infancy
A Retrospective Clinical Study
Alonim H.
The Mifne Center, Rosh Pinna & Bar Ilan University, Ramat Gan, Israel
Summary
The phenomenon of autism reached worrying dimensions all over the world. In Israel children are
usually diagnosed at age two, but even this age may be too late, since the critical stage at which it is significantly
possible to influence development is in infancy due to the dynamism of the brain at this stage. A study conducted
at the Mifne Center examined 110 infants who were diagnosed with autism between the age of two-three years,
using retrospective analysis of home video-recordings of their first year of life (before any suspicion concerning
defective development arose). In the video-records of 98 of the babies it was possible to identify early signs
which pointed to autism characteristics and have been referred to as red lights.
Introduction
In the early 1980s there were reported two cases of autism per every five thousand (2:5000) children
(National Autistic Society, 2006). A widening of the definition of Pervasive Developmental Disorder in the
DSM-IV (1994) led to an increase of two cases per thousand children (2:1000). Children were not diagnosed
before school entry. In the last decade with increasing awareness of the phenomenon of autism, diagnostic tools
have improved and the age of diagnosis has been significantly lowered. In 2010 the phenomenon reached
worrying dimensions with reports of one case per hundred children (1:100) in the USA and one per two
hundreds (1:200) in Israel.
Present knowledge is apparently just the tip of the iceberg. Findings indicate the influence of genetic
factors associated with environmental aspects, although it is still not possible to isolate and differntiate among
them. The assumption is that as the population grows, new mutations emerge in the human gnome, adhering to
the polymorphs of the chromosomes A or B and contributing to the development of the autistic symdrome
(International HapMap, 2003).
Currently in Israel, children are usually diagnosed at an early age (two years) but even this may be too
late since the critical stage at which it is still possible to significantly influence development is in the very early
infancy (Baumann, 2003, Alonim, 2007).
For many years, when parents of children with autism were asked when they first discerned that
something was irregular in their child's development, they would answer either "our child developed normally
until the age of one year and then the regression began," or "I felt from the start that something was not right
with my child but everyone said that I was a hysterical mother."
A retrospective study conducted at the Mifne Center over the last decade examined 110 babies who
were diagnosed with autism at the age of two-three years.
Methods
The study used retrospective analysis of video-recordings of the infant's first year of life, recorded by
their parents before any suspicion concerning defective development arose.
The videotapes of the 110 infants from Israel and overseas had recorded the infants from the age of
several weeks at a high frequency that naturally differed from family to family. The videos were taken during
daily routine, e.g. interatcion, feeding, bathing, and playing. In addition to the video data, questionnaires were
distributed to the parents. Variables investigated were: passivity, activity, eye contact, reaction to parents'
presence, eating, reaction to touch, motor development and head circumference. All variables were measured
blindly according to a validated evaluation form.
© Medimond . Q517C0010
1
Results
Findings show that signs related to autism characteristics appeared in 98 infants; some were quite minor
to be noticed by parents at the time. Additionally, 6 infants showed (physio-neurological) indices, and 6 infants
did not show any signs related to autism.
The following signs were found to appear frequently in the infants studied, and are thus referred to as
red lights:
1.
2.
3.
4.
5.
6.
7.
8.
Over-passivity – lack of crying, lack of movement, lack of interest in surroundings; these infants do not
reveal any initial interest in their surroundings, as can already be seen at at the age of three months.
Hyper-activity – continuous crying unrelated to any medical cause and lack of physical tranquility; these
infants cannot 'find their place', moving or crying restlessly during most hours of the day.
Resistance to eat – a large percentage of children within the autistic spectrum, already exhibit a failure to
assimilate appropriate eating habits during the first weeks or months of their lives. Difficulties in feeding,
transition to fruits or solids, refusal to eat may testify to a lack of sensory regulation.
No reaction to sound or parents' presence – does not turn head towards person, smile or mutter; an
infant with hearing loss reacts to the presence of a parent and reacts to facial gestures. In case of this sign, a
thorough hearing examination is essential in order to distinguish between lack of reaction to sound and lack
of reaction to presence.
Withdrawal from parental touch or touch of any other person – 'flooded' infants may have sensory and
tactile over-sensitivity and therefore recoil from or feel uncomfortable with physical contact.
Lack of direct eye contact with people (although eye contact with objects exists) – eye contact has
decisive emotional influence on mutual bonding with others. Infants who have difficulty making eye
contact with people do not usually have difficulty making eye contact with objects.
Delayed motor development – the motor development of an infant with an attachment disorder is often
characterised by hypotonia and delayed motor development. Alternatively it is also possible to see infants
with hypertonia. This sign is not significant since some infants diagnosed with autism exhibit rapid motor
development.
Accelerated growth of the circumference of the head in relation to starting point – some children
diagnosed with autism had small head circumferences after birth, but within a year the circumference grew
rapidly in comparison to the development of normal toddlers (Courshence, 2003). This sign is also not
significant. Accelerated development of the head can also indicate other syndromes.
Discussion
The advantage of diagnosis during infancy stems from the dynamism of the brain at this stage. The most
accelerated growth of neurons occurs in the first 18 months of life (Baumann, 2003), creating a complex texture
of cells that control the infant's sensory-emotional-cognitive regulation. An infant that avoids contact with the
environment is usually inundated by sensory flooding, and cannot contain this overwhelming flooding (Tustin,
1981). During the development of emotion, that influences interpersonal and social abilities, neurological and
neuro-chemical systems are involved and direct the level of emotional regulation (Trevarthen, 2000).
Moreover, when an infant does not immediately react to the parents, they tend naturally to develop
anxieties that may radiate to the infant and thus create a snowball effect. This means that it is essential to work
with parents already at this early stage (Alonim, 2004).
There is a debate about the essence of attachment and its connection to autism. The researcher's
assumption is not every infant who displays attachment difficulties will necessarily develop autism, but any
child with autism, initially exhibited attachment or interaction difficulies.
The main question that arises from the results of this study, taking into consideration the plasticity of
the brain at this age, is whether we should lower the detection of autism to the age of one?
Conclusions
Early signs of autism can often be observed in the infant's first year of life. Identification and treatment
by appropriate stimulation in the first year of life combined with parents' therapy can alter the process of
development for very young infant that exhibits difficulties in sensory regulation and bonding, and may
minimize the accleration of autism.
2
Outcomes
As a result of this study, the Mifne Center developed the Eearly Signs of Pre Autism Scale for Infants,
ESPASI (Alonim, 2007), which is used at the the pioneer Unit of Autism Detection in Infants at the Tel Aviv
Sourasky Medical Center.
The following two criteria may justify an evaluation:
a)
b)
The existence of at least two of the eight signs (excluding signs 7 and 8), continuously during a period of
at least three weeks.
All relevant medical examinations (metabolical, neurological audilogical, visual) should be performed
before investigating suspicion of any disorder connecting to autism.
References
Alonim, A.H., Infants at Risk: Early Signs of Autism: Diagnosis and Ttreatment. In: A.H. Alonim, S.
Acquarone, G. Crespin, L. Danon-Boileau, S. Maestro, H. Massie, F. Muratori, M. Rhode & C.
Trevarthen, eds. Signs of Autism in Infants: Recognition and Early Intervention. London: Karnac Books.
Ch. 7. 2007
Alonim, A. H., The Mifne method. Journal of Child and Adolescent Mental Health, Vol. 16, pp. 39-43. 2004
American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders. 4th ed.
Washington, DC: American Psychiatric Association. 1994
Bauman, M., Autism: Clinical Features and Neurobiological Observations. In: H. Tager-Flusberg, ed.
Neurodevelopmental Disorders. Cambridge, MA: MIT Press, pp. 383-399. 2003
Courchesne, E., Carper, R. & Akshoomoff, N., Evidence of Brain Overgrowth in the First Year of Life in
Autism. Journal of the American Medical Association, 290, pp. 337-344. 2003
International HapMap Consortium. A Haplotype map of the human genome. Nature, 437, pp.1299-1320. 2003
National Autistic Society. Public Autism Resource and Information Service, [Online]. Available at:
http://www.info.autism.org.uk [Accessed 1 November 2006].
Trevarthen, C., Autism as a Neurodevelopment Disorder Affecting Communication and Learning in Early
Childhood: Parental Origins, Post-Natal Course and Effective Educational Support. Prostoglandins,
leucotrines and Essential fatty Acids, 63(1), pp.41-46. 2000
Tustin, F., Autistic States in Children. London, Boston and Henley: Routledge & Kegan Paul. 1981
The study was granted by the Swiss Mifne Foundation.
All rights reserved © May 2011
3
Addressing the childhood obesity epidemic: The
Healthy Bodies and Healthy Minds project.
Bateman H., Duncham H. & Maxwell L.
Sewanee: The University of the South
Sewanee, Tennessee, U.S.A
Summary
The incidence of childhood obesity is increasing at an alarming rate in many industrialized and
developing societies. Childhood obesity has been found to have a detrimental effect on many aspects of
children’s development. The Healthy Bodies and Healthy Minds research project was created with the goal of
battling childhood obesity by providing school-age children with: a) information about proper nutrition, b) tools
with which they can make healthier food choices, c) an increased awareness of the importance of exercise for
sustaining good health, and d) the experience of exercise as an engaging activity that is accessible to all children
(regardless of their weight). Data collected from the first year of the project suggest that children participating in
the project increased: a) their level of understanding of nutritional information for all food groups, and b) their
ability to make healthier food choices.
Introduction
Prevalence of childhood obesity
A recent comparison of 34 countries revealed that the United States has the second highest rate of
obesity of children and adolescents with 25.1% of children between the ages of 10 and 16 classified as pre-obese
and 6.8% of children classified as obese. Since 1970 the incidence of childhood obesity has increased more than
50 percent among children between the ages of 6 and 11 and nearly as much between the ages of 12 and 17
(Houpt, 2003). The most recent National Health and Nutrition Examination Survey (NHAMES) (collected
1999-2002) shows that, among children aged 6 through 19 years, the prevalence of overweight is three times
greater than the goals established in Healthy People 2010 (Hedley, Ogden, Johnson, Carroll, Curtin, & Flegal,
2004).
Physiological correlates of childhood obesity
There are multiple deleterious health consequences to obese youth: an increased risk of pulmonary,
endocrine, coronary, neurological, renal, and musculoskeletal problems such as asthma, type 2 diabetes,
proteinuria, hypertension, higher risk for stroke, and Blound’s disease (Choudhary, Donnelly, Racadio, & Strife,
2007).
Social and psychological correlates of childhood obesity
Existing research suggests that obese children suffer from a number of psychological and social
problems. More specifically, obese children are often rejected by their peers. Obese children often suffer from
low self-esteem and exhibit higher levels of anxiety and depression (McClanahan, Huff, & Omar, 2009).
In terms of the long-term consequences of childhood obesity on one’s economic circumstances, women
who remain obese through childhood and adolescence--when compared to those whose weight was normal
during childhood—had less schooling, lower household incomes, and double the risk of living in poverty when
compared to women who were not obese throughout their lives (Gortmaker, Must, Perrin, Sobol, & Dietz, 1993).
Causes of the increased rates of childhood obesity
Several life-style and environmental factors have been linked to the increasing rates of childhood
obesity. Two of the factors that have been identified as the primary reasons behind the epidemic of childhood
obesity are: a) changes in children’s diet (e.g., increases in dietary fat, sugar, refined flour), and b) reduction in
5
children’s activity levels (e.g., less physical exercise, less physical activity/play, more television watching/video
games) (Anderson & Butcher, 2006).
The Healthy Bodies and Healthy Minds program
The Healthy Bodies and Healthy Minds research project (HB&HM) was created with the goal of
battling childhood obesity by providing school-age children with: a) information about proper nutrition, b) tools
with which they can make healthier food choices, c) an increased awareness of the importance of exercise for
sustaining good health, and d) the experience of exercise as an engaging activity that is accessible to all children
(regardless of their weight)
Program description
The program is directed at children ages six to thirteen. The program is divided into units (each unit
represents a particular area of nutrition) and each unit is divided into individual lessons. The program takes
place in schools after the end of the regular school hours. Each session covers one lesson and lasts 60-75
minutes. Each lesson is comprised of two major components: a) nutrition education and b) exercise.
During the nutrition education component students learn information about the nutritional value of food,
the importance of eating a nutritious diet, and the relationship between eating certain types of food and one’s
health and physical well-being. During this component of the program students are encouraged to actively
participate in the learning process, engaging in hands-on activities such as putting together a nutritional snack,
and tasting healthy foods such as fresh fruits and vegetables and whole grain products.
In the second component of each lesson, students engage in physical exercise. The exercise activities
are created with the goal of increasing students’ interest in physical activity and their confidence in being able to
become more physically active regardless of their weight.
The program is implemented by teams of instructors (each team is comprised of five to six instructors)
who are trained extensively prior to interacting with the students. The teams are comprised of faculty and
undergraduate college students who are participating in this project as part of their community-engagement
research requirement in their child development and community psychology courses.
In addition to college faculty and students, the Healthy Bodies and Healthy Minds teams also include
chefs who are committed to preparing tasty and healthy food for children, and local organic farmers who provide
advice on how to grow vegetables and fruits and how to locate, prepare, and eat seasonal local produce.
Throughout the program we provide students with recipes, nutrition and exercise tips, and, on occasion,
small sample items of seasonal vegetables and fruits (locally grown whenever possible) to take home and try
with their parents. In late spring (at the end of the program) we provide students with tomato plants to take
home and grow over the summer. These activities have as their goal the inclusion of the parents in the Healthy
Bodies and Healthy Minds program.
In addition to the after-school sessions, we—whenever possible--offer a field trip to the students in
which they get to visit local vegetable and fruit gardens, play sports taught by college athletes, and watch
demonstrations of healthy cooking by chefs.
Finally, we provide schools with the opportunity to have students involved in starting their own
vegetable garden at the school and learning more about fruits and vegetables by helping grow them. We help by
providing materials, advice, and experts to help schools start their vegetable garden.
Assessment
This paper presents the findings from a one-year pilot study of the Healthy Bodies and Healthy Minds
program.
Materials and Methods
Participants
Twenty children ranging in age from six to thirteen years of age participated in the HB&HM afterschool pilot program. All children were students in a public school located in a rural area of the Southeastern
United States. Participation in the HB&HM after-school program was voluntary and the number of children
participating in each session varied a great deal. All children participating in the program were Caucasian. Forty
percent of the participants were boys and sixty percent of the participants were girls.
6
Procedure
The pilot program consisted of after-school sessions in which consenting students participated in a 30minute nutrition education program aimed at increasing their knowledge of nutrition and their understanding of
healthy eating habits, followed by a 30-minute exercise program aimed at encouraging them to engage in
physical activity regardless of their present level of physical fitness. The nutrition education component of the
program was evaluated with a series of pre- and post-tests. More specifically, students completed a pre-test prior
to the onset of each nutrition lesson and then completed the same test after they participated in the nutrition
education program (post-test). A total of four lessons were implemented during the pilot study.
Materials
Paper and pencil pre- and post-tests were created to evaluate students’ learning. These tests were
comprised of the following components: a) multiple choice, b) fill-in the blank, c) writing names of foods in the
right place (i.e., the food pyramid test). Each lesson had a unique measure created to test students’ learning of the
information presented in this particular lesson.
Results
Assessment of Lesson 1: “How the Body Works” contained three questions (one yes/no and two
multiple choice) testing children’s understanding of the lesson. Seventeen children participated in this
assessment. Figure 1 depicts the number of correct answers for each of the three questions before and after this
lesson.
Assessment of Lesson 2: “The Food Pyramid”, contained the diagram of the U.S. Food & Drugs
Administration (FDA) “Food Pyramid” without any text. Students were asked to circle the right answer about the
use of the pyramid and then write on the diagram the correct food category for each section of the pyramid.
Fifteen children participated in this assessment. The numbers of correct food/pyramid choices for each student
are reported in Figure 2 (question 1). The total number of correct food groups per pyramid section and the total
number of correct examples for each food group are depicted in Figure 3 (questions 2 & 3 respectively).
Assessment of Lesson 3: “An introduction to food nutrients (Part 1)”, contained three open-ended
questions asking children to write information about the types of vitamins contained in fruit, the best way to get
complex carbohydrates, and the best way to get calcium from food. Nineteen children participated in this
assessment. The total number of vitamins named are depicted in Figure 4. The total number of correct
responses that children generated for questions 2 & 3 are depicted in Figure 5.
Assessment of Lesson 4: “An introduction to food nutrients (Part 2)” contained three questions (one
open-ended and two multiple-choice) asking children to write the type of nutrients that help muscle growth and
to select among several choices the type of food with the most protein and the most iron. Seven students
participated in this assessment. The total numbers of students that answered each question correctly before and
after the lesson for questions 1, 2, & 3 are depicted in Figure 6.
7
8
Conclusion
Results from the Healthy Bodies and Healthy Minds pilot study suggest that children who participated
in the HB&HM pilot program substantially increased their knowledge of nutrition. There were several
limitations in this pilot study. Due to the pilot status of the research a small number of children from one school
only participated in the program. We also lacked a comparison group against which the benefits of the program
can be compared. Future implementations of the Healthy Bodies and Healthy Mind program will include
additional schools in a staggered cohort design in which cohorts entering the program at later times will serve as
comparison groups to cohorts starting the program earlier.
9
References
ANDERSON, P. M., & BUTCHER, K. F.. Childhood Obesity: Trends and Potential Causes. The Future Of
Children, 16(1), 19-45, 2006.
CHOUDHARY, A., DONNELLY, L., RACADIO, J. & STRIFE, J. Diseases Associated with Childhood
Obesity. American Journal of Roentgenology, 188(4), 1118-1130, 2007.
GORTMAKER, S., MUST, A., PERRIN, J., SOBOL, A., & DIETZ, W. Social and economic consequences of
overweight in adolescence and young adulthood. N Engl J Med , 329 (14), 1008-1012, 1993.
HEDLEY, A, OGDEN, C., JOHNSON, C., CARROLL, M., CURTIN, L., & FLEGAL, K. Prevalence of
overweight and obesity among US children, adolescents, and adults, JAMA, 291(23), 2847-2850, 2004.
HOUPT M.I. Childhood Obesity: A growing epidemic. Pediatr Dent, 25(5), 422, 2003
MCCLANAHAN, K. K., HUFF, M. B., & OMAR, H. A.. Overweight children and adolescents: Impact on
psychological and social development. International Journal Of Child Health And Human Development,
1(4), 377-384, 2009..
10
Use of Internet and online interactions in a Brazilian
sample
Ferreira P. P.¹, Bolsoni-Silva A.T.²
¹ Postgraduate Program in Developmental Psychology and Learning, Universidade Estadual Paulista “Julio de
Mesquita Filho” UNESP, Bauru, Brasil
² Psychology Department, Universidade Estadual Paulista “Julio de Mesquita Filho” UNESP, Bauru, Brasil
e-mail: priferreira.sn@uol.com.br
This article originated from a survey supported by FAPESP (Fundação de Apoio à Pesquisa do Estado de São
Paulo)
Summary
This work focused on the use of internet and online interactions and was based on data collected from a
sample of Brazilian college students (64 people) who were asked to answer the Face-to-Face and Online
Interaction Survey. The outcomes are analyzed in this paper and from them it is possible to observe patterns on
internet interaction. It was also possible to conclude that the sample frequently uses the Internet, its online
interactions and that this kind of interaction is used as a complement to face-to-face communication.
Keywords: Internet, Interpersonal interaction, Online interaction.
Introduction
In Brazil, a recent survey shows that 49% of Brazilians who are over 10 years old had used the Internet
in the last three months before the survey (Comitê Gestor da Internet no Brasil, 2013). The same survey points
out that 69% of people who use the Internet, do it every day and 89% of them use the Internet with
communication purposes.
Online communication is emerging as a possibility to satisfy social needs (Peris et al., 2002). The online
environment can be used to interact with both known and unknown people. Valkenburg and Peter (2007)
concluded that adolescents use the Internet mainly to maintain and enhance the closeness of pre-existing friends.
These authors also affirm that adolescents commonly use instant messengers to interact online, but they also
interact through public chat rooms and social network sites.
College students have to use the Internet for many reasons, from assignments and academic research to
interaction with other people, university colleagues, family, and friends outside the university. It is noteworthy
that a large proportion of college students in Brazil move to another city to study in a university. It is remarkable
that 72% of Brazilians who finish high school and 93% of graduated people use the Internet (Comite Gestor da
Internet no Brasil, 2013), percentages expressively higher than the general population as shown above.
Social interaction has been indicated as an important factor related to college dropout. Bardagi and Hutz
(2012) point that interpersonal relationship is important in the process of postponing the decision to drop out
when the relationship is seen positively and interpersonal relationship problems may be determinant in the
decision of dropping out a course. Considering the importance of social interaction in this stage of life and the
high use of Internet and online interaction for these people, the purpose of this survey is to analyze how a sample
of Brazilian college students uses the Internet and how they interact in this environment.
Methods
Participants
Sixty four Brazilian college students participated in this survey. There were 31 men and 33 women.
Their ages ranged between 18 to 38 years (average 22 and standard deviation 3) and they were from different
faculties of a public State University. These students had participated in a previous survey about social skills,
phobia and depression (Bolsoni-Silva, 2011).
11
Measures
The participants answered the Face-to-Face and Online Interaction Survey. This survey investigates
online interactions frequency; places where people access the Internet; online activities; how people met those
with whom they interact online; number of people with whom they interact online, offline, and both; how they
define the relationship with the people they interact with (for example: friends or colleagues); difficulties or
benefits in dealing with certain subjects online and face-to-face; and if there is some subject that they talk about
on the Internet but not face-to-face.
The Face-to-Face and Online Interaction Survey was preliminarily validated, achieving as Cronbach’s
alpha: 0,847 (Ferreira, 2012). This score indicates good psychometric indices.
Procedure
Participants answered the survey individually or collectively. During the application participants were
informed about the objectives of the survey and they signed a consent form to the terms of the survey.
The data was tabulated in spreadsheets on the computer. Concerning the large amount of data provided
for the survey, only part of the data will be used in this paper. It will be analyzed according to the responses
frequency.
Results
All the participants stated that they use the Internet. The frequency of Internet use of the participants
and the frequency of online interaction (in hours per week) is shown in Figure 1.
Figure 1: Left: numbers of hours online per week. Right: qualitative self-assessment on frequency of online interaction
As is shown in the Figure 1, the frequency of internet use is: 8% less than five hours, 14% between five
and fifteen hours, 23% between 15 and 25 hours, 23% between 25 and 35 hours and 31% more than 35 hours. It
is remarkable that the Internet is a tool largely used by the participants of this survey. Other Brazilian survey
found similar results, pointing out that college students are the group who spend more time online, about 84
hours per month (IBOPE, 2013).
Figure 1 also presents the results of the qualitative self-assessment on online interaction: 2% of the
participants rarely interact online; 5% infrequently, 17% sometimes, 28% often; 47% always; and one person did
not answer this question. Therefore, online interaction is highly used by these participants when they are on the
Internet.
Concerning the places where they use the Internet, participants stated that 77% of them use the Internet
in a common area in their houses (such as the living room), 70% use the Internet in a privative area in their
houses (such as the bedroom), 42% in their workplace, 70% at the university, 28% in Internet Cafes and 19% in
other places. It is noteworthy that they access the Internet in different places they visit.
When they were asked about the online activities, 97% stated they use the Internet to send and receive
e-mails; 38% to chat on chat-rooms; 94% to use instant messengers; 97% to access social network sites; 56% to
visit blogs, photo blogs and Twitter; 45% to update their own blogs, photo blogs and Twitters; 47% to play
games that involve social interaction; 50% to play games that do not involve social interaction; 81% to read the
news; 98% to do academic research; 78% to do other kinds of research; 75% to keep in touch with personal and
professional contacts; and 8% to do other activities. There is a large variety of activities performed online. The
ones that stand out are academic research and different forms of interaction, as e-mails, instant messengers and
social network sites. The use about academic research is according to the necessity of research at the university.
12
The communication outcomes are according to Valkenburg and Peter (2007), who say that the communication is
the most predominant purpose of Internet using.
Regarding how they interact with other people, 92% of them interact using e-mails; 33% using chat
rooms; 94% using instant messengers; 92% using social networking sites; 45% using blogs, photo blogs and
Twitter; 41% using games and 8% using other resources. It may be noticed that they interact using different
tools, mainly e-mails, instant messengers and social network sites.
The outcomes of this survey are according to Valkenburg and Peter’s (2007) and Peris et al.’s (2002)
results. Valkenburg and Peter (2007) found that 97% of the participants used instant messengers; it is almost the
same as the participants in this survey (94%). Peris et al. (2002) survey found a slightly lower result (81.8%).
These authors also found a lower value in e-mail use (69.7% against 92% in this research) and a higher value in
chat rooms use (81.8% against 33% in this survey).
Regarding how the participants met the people with whom they interact online, 39% interact with
people whom they met using e-mails; 31% using chat rooms; 58% using instant messengers; 47% using social
network sites; 33% using blogs, photo blogs and Twitter; 30% using games; 84% had already met each other
face-to-face; and 4% had met the people in different places. It is important to notice that they interact primarily
with people they had met face-to-face. Nevertheless, they are most likely to meet people using instant
messengers and social network sites.
The outcomes of the number of people the participants interact just online, just face-to-face and both,
online and face-to-face, the outcomes are in Table 1.
Table 1 – How much people participants interact with: just online, just face-to-face and both online and face-to-face (in
percentage).
Just online
Just face-to-face
Both online and
face-to-face
1 or 2
people
17%
3%
5%
2 to 5
people
20%
6%
6%
5 to 10
people
17%
14%
11%
10 to 15
people
3%
11%
12%
More than
15 people
14%
55%
61%
No one
28%
11%
5%
It is possible to see that the participants interact just online with remarkably fewer people than they
interact just face-to-face and both online and face-to-face. The highest percentage of participants interacts both
online and face-to-face with other people. In addition, 66% of the participants answered that they interact with
more people throughout the day face-to-face; 6% interact more online and 28% interact both offline and online
to the same extent. Following the same trend, concerning the impact of online interaction in their face-to-face
interaction, 22% of them think that online communication increased the amount of time they spend with family
and friends, 25% think that this communication decreased the amount of time they spend with family and friends
and 52% think that online communication did not affect the amount of time they spend with family and friends.
One person did not answer this question. Therefore, it is possible to say that, for these participants, online
interaction complements instead of replacing face-to-face interaction. Peris et al. (2002) concludes something
similar to it in their research, they say that the chat rooms can work as another possibility to satisfy interaction
needs of people.
Regarding the existence of subjects that they talk about online but not face-to-face, 47% of the
participants stated that there are things they talk about on the Internet but do not do it face-to-face and 48% that
all they talk online, they also talk in face-to-face situations. Three people did not answer this question. It is
possible to notice that there is no tendency on this topic. Peter and Valkenburg (2007) also found that the
perception of the participants about online communication varied greatly, with 25% perceiving online interaction
as more effective to discuss a variety of topics and 30% perceiving online communication as more effective to
self-disclose intimate information.
Conclusions
It is possible to conclude that this Brazilian sample uses often the Internet and its online interaction
tools. Nevertheless, it does not imply in a decrease of face-to-face interaction, on the contrary both forms of
interaction complement each other. The results also provide insights on how people interact online. It is
important to note this is a preliminary work based on a small sample and the survey tool used has not been
validated yet. Because of this, more work is necessary to make it possible to know more about Internet uses and
online interactions in Brazilian college students and in older or younger people.
13
References
BARDAGI, M. P.; HUTZ, C. S.. Rotina Acadêmica e Relação com Colegas e Professores: impacto na evasão
universitária, PSICO, Porto Alegre, PUCRS, v. 43 , n. 2, p. 174-184, 2012.
BOLSONI-SILVA, A. T.. Habilidades sociais e saúde mental de estudantes universitários: construção e
validação do Q-ACC-VU e estudos clínicos em análise do comportamento, (Thesis, Universidade Estadual
Paulista, Bauru), 2011.
COMITÊ GESTOR DA INTERNET NO BRASIL. TIC Domicílios e empresas 2012 pesquisa sobre o uso das
tecnologias de informação e comunicação no Brasil, São Paulo, 2013.
FERREIRA, P. P. Interações virtuais e presenciais em universitários com e sem indicativo de fobia social, (MSc
Thesis, Universidade Estadual Paulista, Bauru), 2013.
IBOPE. Homens estão em maior número e navegam mais tempo na internet do que as mulheres. 2013,
September,
16.
Retrieved
January
13,
2014,
from:
<http://www.ibope.com.br/ptbr/noticias/Paginas/Homens-estao-em-maior-numero-e-navegam-mais-tempo-na-internet-do-que-asmulheres.aspx>
PERIS, R. et al.. Online chat rooms: Virtual spaces of interaction for socially oriented people. Cyberpsychology
& Behavior, New Rochelle, v. 5, n. 1, p.43-51, 2002.
VALKENBURG, P. M.; PETER, J.. Preadolescents’ and adolescents’ online communication and their closeness
to friends, Developmental Psychology, Ann Arbor, v. 43, n. 2, p.267-277, 2007.
14
Passive Client Representation Hinders Vision
Rehabilitation Professionals effectiveness
Cordella B.1, Greco F.2, Grasso M.3
1and 3
Department of Clinical and Dynamic Psychology, Sapienza University of Rome (Italy)
Department of Social Science and Economics, Sapienza University of Rome (Italy)
e-mail: francesca.greco@uniroma1.it
2
Abstract
Vision Rehabilitation Centres could be the place where to develop or improve useful abilities aimed to
facilitate people with disability in becoming self-sufficient and independent. The culture of professionals
working in these organizations can either facilitate or hinder this process, the aim of this study is to explore it in
order to (a) understand the way each professional role represents the relationship with the client with visual
disability and to (b) identify the role psychologists could usefully play in this process.
For this reason, professionals working in an Italian Vision Rehabilitation Centre (n=34) were
interviewed. The interview transcriptions underwent an Emotional Text Analysis with a computer software
package (T-Lab).
Results show 4 cultural repertoires highlighting different representations of the rehabilitation and of the
client with disability. Each professional role represents the process differently, as management, diagnosis,
training or advocacy. All the participants represent the client with disability as passive. This affects
professionals’ performance reducing their effectiveness in motivating their clients in taking on an active role in
the management of their own conditions.
Therefore, psychologists could play a useful role promoting the client’s active participation, helping
him/her in developing his/her personal commitment to the treatment, and helping the professionals team to
develop an active representation of the client. This would improve their effectiveness and their ability in
managing what should be a working alliance.
Keywords: Culture, Practitioners, Visual Impairment, Rehabilitation, Text Analysis.
1. Introduction
As it has been stated by the Convention on the Rights of Persons with Disabilities of the United
Nations, rehabilitation is a right for those who have long-term physical, mental, intellectual or sensory
impairment. Rehabilitation services and programs should enable people with disabilities “… to attain and
maintain maximum independence, full physical, mental, social and vocational ability, and full inclusion and
participation in all aspects of life” [1]. Therefore, the United Nations suggests that efforts should be made
particularly in the areas of health, employment and education.
In particular this study concerns visual impairment, which is a significant loss of vision that cannot be
corrected by refraction or treatment. This implies that health care professionals have to face a process in which
medical intervention is limited. Adults with disability experience a wide range of behavioural restrictions that
result in loss of independence often associated with a loss of social and economical status for blind people and
for their families as well [2-5]. In Italy over 300000 people are legally blind and the cost of disability benefits for
the unemployment of adults with disability is estimated at 9 billion euros [6]. But, this cost is even higher, if the
loss of productivity due to high rate of unemployment is considered. In fact, people with sensory disabilities are
five times more likely to be unemployed than others in Italy [7-8].
That is why the rehabilitation of people with disability in adult age is a challenge for vision
rehabilitation professionals. In fact vision rehabilitation programs play a key role in addressing restrictions posed
by visual impairment, building new skills and strategies to enhance independence and improve social and
economical status. Thus indirectly, they reduce the costs of disability for the country. That is why effectiveness
is not only morally valuable, but it has also social and economical implications providing people with disability
with useful skills which support them in performing everyday life tasks. Unfortunately, there is currently no
consensus regarding which particular approach is considered to be more effective. In fact, recent studies have
15
suggested that enhanced, comprehensive vision rehabilitation programs do not improve quality of life more than
standard optometric care, or have a modest impact on quality of life [9-11].
Different models of rehabilitation exist and vary widely in intensity, although the majorities involve
provision of aids, devices and training to enhance the use of residual abilities. Besides, a few recent studies
suggest that taking responsibility for managing their own conditions with support and advice from health care
professionals, is an important factor in the rehabilitation process for patients with chronic conditions [12-14].
This is different from teaching particular solutions or making changes to the patient’s home environment.
Therefore, the person with disability needs to be motivated to assume an active role in the process. This new
paradigm in health care aims to provide the client with skills and resources to manage the practical, social and
emotional consequences of his/her visual impairment and to seek specialist support when needed. Nevertheless,
the extent to which vision rehabilitation is provided in this manner will vary according to the culture of the
Rehabilitation Centre and the approach of its professionals [15].
In this study, according to a psychodynamic perspective, the culture is intended as the product of an
unconscious process, relying on a double modality of functioning of the mind [16], setting social representations
[17-18]. People consciously classify reality and, at the same time, emotionally categorize it through an
unconscious process which assigns an emotional meaning to it. Therefore the culture is the emotional
categorizations, socially built and shared, setting individuals’ behaviours, relationships and productivity within
their social context [19]. Hence, the culture results in a set of representations through which an unconscious
meaning is given to objects, as professional roles, goals and disability. The meaning, that is, the outcome in
terms of investment in the relationship practitioners have with their organizations [20]. Therefore, such culture
has a local character, as it is specific of a group of people sharing the same context [21].
Therefore the culture shared by professionals working in a Rehabilitation Centre sets a particular
representation of the clients with disability [22], determining their attitudes and practices toward them and
influencing the working alliance effectiveness. Although some studies address practitioners’ cultural belief [23],
there are few studies on Vision Rehabilitation Centres and they often look at it from the client’s point of view
[24]. Therefore, the aim of this study is to explore the culture of professionals working in a Rehabilitation Centre
in order to understand whether it hinders or facilitates them in effectively motivating their clients to take an
active role in the rehabilitation process and to identify the role psychologists could usefully play in this process.
2. Methodology
To understand a local culture it is possible to explore the expressions it produces, whatever they may
be: art, dance, behaviour, etc. In this study the narrations produced by practitioners working in a Rehabilitation
Centre will be analysed with a specific psychological methodology named Emotional Text Analysis [25].
According to its authors, this method makes it possible to get the emotional unconscious meaning carried by the
text, erasing the original logic connections of the intentional narration and focusing mostly on the words used to
talk about a topic and how they co-occur in the text. Hence, the focus is on how it is narrated and not on what has
been narrated.
2.1. Sample
The research was conducted in a Vision Rehabilitation Centre accredited by a Regional National Health
Service Board. It serves the centre and south areas of the country and offers many services including the
rehabilitation of blind and visually impaired people of all ages. The staff working in the Vision Rehabilitation
Service (table 1) is a multidisciplinary team which sets several treatments according with the age of the person
with disability:
- the residential treatment for adults and young adults (n= 55 per year),
- the semi-residential treatment starting from 12 years old (n=20 per years)
- the outpatient treatment for children starting from 0 years old (n= 20 per year)
The study research project was presented to the medical director of the Centre who in turn informed
professionals working in the Rehabilitation Service. All of them (n=34) (tab. 1) accepted to participate to the
study and signed an informed consent.
16
Tab. 1. Practitioners working in the Vision Rehabilitation Service
Profession
Speech Therapist
Music Therapist
Neuropsychiatrist
Nurses
Occupational Therapist
Ophthalmologist
Optometrist
Physiotherapist
Psychiatrist
Psychologist
Psychomotor Therapist
Social Worker
Educational Assistant
Vision Rehabilitation Therapist
Total
N°
2
1
4
2
1
1
2
1
1
2
3
1
3
10
34
The first column shows the professional roles of practitioners working in the service and the second their number
2.2. Data collection and analysis
First the role performed by the interviewee was recorded (tab. 1) then the interviewer asked him/her:
“Could you tell me about your professional experience of rehabilitation of people with disability in this
Service?” The face-to-face interview was audio recorded and conducted always by the same researcher.
The interview option matches the explorative aim of the research, allowing to freely express
interviewees’ thoughts, beliefs and the complexity and specificity of their own experience, preventing
penalization by pre-set interpretation categories of the researcher. This methodology drives the interviewee to
reconstruct the phenomenon free from external influences and fosters the disclosure of different representations
of the world. As a consequence, the aim of this methodology setting is to understand before explaining, by
establishing a direct human relationship. By being asked a very general question, the flow of the participant’s
thoughts will be elicited using his/her words and reasoning structures.
Data collection was performed in a quiet room of the centre with a non-directive conversation style, free
from evaluation or judgment. The interviewer supported participants’ narrations without suggesting any words
either than those proposed by the interviewee and the stimulus question.
The narrations produced by the interviewees were audio recorded and integrally transcribed and the
transcripts were collected together in a corpus. In order to classify each text according to the professional role of
the narrator, texts were labelled with a nominal variable. Due to the variety of professional roles present in the
Service they were grouped in four categories (physicians, paramedics, psycho-social workers and vision
rehabilitation practitioners), as shown in tab. 2.
Tab. 2. Texts classification according to the professional role.
Professional Roles
Neuropsychiatrist
Ophthalmologist
Psychiatrist
Speech Therapist
Music Therapist
Nurse
Occupational Therapist
Optometrist
Physiotherapist
Psychomotor Therapist
Psychologist
Social Worker
Vision Rehabilitation Therapist
N°
4
1
1
2
1
2
1
2
1
3
2
1
10
Tutors
Practitioners in total
3
34
Categories of the nominal variable
PHYSICIANS
N° of texts
6
PARAMEDICS
12
PSYCHO-SOCIAL WORKERS
3
VISION REHABILITATION PROFESSIONALS
(VRP)
13
17
Professional roles (first column) and the number of participants who perform them (second column) are grouped in the four
categories of the nominal variable (third column). The fourth column highlight the total number of texts (interviews)
belonging to each categories.
Then the corpus was processed with a computer software package of text analysis (T-Lab) [26]. T-lab
performed a cluster analysis and a correspondence analysis to identify groups of lemmas having high within and
between variance. This analysis aims to identify revealing words that characterize professionals’ culture, which
is the way they represent their function, their clients with disability and the rehabilitation process. Clusters
distribution was also detected according to the professional role.
2.3. Data Interpretation
In the emotional text analysis, the interpretation process looks for the emotional link that ties together
the words composing clusters and factors. This process has been supported by the etymological analysis of the
words which suggest more meaning than those detectable relaying only on the explicit words present in the
narrations thus facilitating data interpretation.
First, the factorial space is interpreted to detect the emotional categories of meaning shared by all
participants, setting the framework in which clusters are located. For this purpose, the words belonging to the
same polarity of the factor, are interpreted to detect the general dimension characterizing it, in contrast with the
opposite polarity. Hence, the interpretation process looks for the general dimension, marking the factor,
conferring a meaning to it and at the same time distinguishing it in two opposite categories, e.g. good and bad.
Then cluster are interpreted according to their position in the cultural space, defined through the emotional
categories of meaning of the factors and the list of words characterizing them.
Data interpretation is performed separately by three trained researchers and, then, results are discussed
and complemented together aiming to define the class of meaning which better synthesises those detected by
each researcher.
3. Results
The results show 3 factors reflecting the general dimensions characterizing the culture of practitioners
working in the Rehabilitation Service and 4 clusters (tab. 3 and 4) highlighting the cultural repertoires emerging
from narrations. They show the way participants relate with their professional role, categorizing emotionally
their function, the person with disability and the rehabilitation process.
Tab. 3. List of words of the factors
First Factor
Negative Polarity
Ragazzo
Utilizzare
Servire
Scrivere
Imparare
Positive Polarity
Boy
Use
Serve
Write
Learn
Lavoro
Utente
Progetto
Equipe
Diverso
Work
User
Project
Team
different
Second Factor
Negative Polarity
Mettere
Utilizzare
Importante
Gioco
Ausilio
Positive Polarity
Put
Use
Important
Game
Assistive Technology
Ragazzo
Anni
Realtà
Cieco
Università
Boy
Years
Reality
Blind
Università
Third Factor
Negative Polarity
Diverso
Bambino
Formazione
Cognitivo
Genitore
Positive Polarity
Different
Child
Training
Cognitive
Parent
Lavoro
Equipe
Bisogno
Utente
Operatore
Work
Team
Need
User
operator
For each polarity of the factor the first 5 words have been listed in Italian (left column) and in English (right column)
18
Tab. 4. List of words of the clusters
CLUSTER 1 (28,1%)
CLUSTER 2 (21,6%)
Lavoro
Work
Utilizzare
Use
Equioe
Team
Mettere
Put
Utente
User
Imparare
Learn
Operatore
Practitioner
Parola
Word
Bisogno
Need
Capacità
Ability
Terapista
Therapist
Importante
Important
Different
Ragazzo
Boy
Years
CLUSTER 3 (28,3%)
Diverso
CLUSTER 4 (22,0%)
Bambino
Child
Anni
Cognitivo
Cognitive
Cieco
Blind
Sviluppo
Development
Università
Università
Formazione
Training
Conoscere
Know
Deficit
Deficit
Realtà
Reality
For each cluster the first 6 words have been listed in Italian (left column) and in English (right column). On the side of the
cluster number between brackets is marked the cluster’s weight, that is the percentage of the corpus classified.
The first factor is the one which mostly explains the text inertia followed by the other two. The factorial
space constitutes a three dimensional Cultural Space in which clusters are located (figure 2 and 3). The first
factor distinguishes cluster 1 and 3 (positive polarity) from cluster 2 and 4 (negative polarity). The first and the
third cluster are the biggest cultural repertoires, which classify 28% of the corpus (p<0,01). The cluster 2 and
cluster 4 are the smallest ones (22%).
Factors 2 and 3 clarify each polarity of the first factor. In fact, factor 2 differentiates only cluster 2
(negative polarity) from cluster 4 (positive polarity) almost not influencing cluster 1 and 3 (fig. 1). Instead, factor
3 differentiates only cluster 1 (positive polarity) from cluster 3 (negative polarity) not concerning the other two
(fig. 2). Therefore the factorial space is not really three-dimensional because the second and third factors explain
only half of the clusters.
Fig. 1. Cluster distribution in the factorial set by factor 1 and 2. Factor 1 is the X axe and factor 2 is the Y axe.
19
Fig. 2. Cluster distribution in the factorial set by factor 1 and 3. Factor 1 is the X axe and factor 3 is the Y axe.
4. Discussion
Results suggest that professionals have the ability to deal with a large variety of problems connected
with visual impairment thanks to their skills and experiences, offering a global intervention to their clients able
to deal with a wide variety of problems. Management, prevention, training and advocacy seem to be the goals of
the rehabilitation process coming out from the clusters.
The first cluster is characterized by the need of managing the working team. Working in a Vision
Rehabilitation Service seems to imply the necessity to work on practitioners’ interaction dealing with different
needs and professional perspectives of the multidisciplinary team. This cluster highlights the additional work
needed to support team work. Besides, the target is the team itself. The person with disability is absent and
professional function is focused on management and coordination. Therefore, this representation of the
rehabilitation process is not visually specific.
In the second cluster the rehabilitation is meant as training. Therefore particular attention is given to
tools and activities. The process is focused on professional intervention by teaching specific solutions thanks to
professional training and experience. The process is considered as morally right and the attention is directed not
on the relationship with someone but on professional performances. Whereas this representation refers to
specific tools, no attention is given to tool employment. Therefore it is possible to assume that rehabilitation is
focused on professional performance rather then on people’s needs.
In the third cluster rehabilitation focuses on the prevention of visual impairment consequences. In fact,
particular attention is given to children whose visual impairment could affect the development process. Hence
professional function is focused on a particular aspect and moment of life. It aims to work on handicaps
associated with visual impairment, especially intellectual ones. Here the client seems to be the child with
disability represented as multi-handicapped and the professional function does not deal directly with visual
impairment.
Cluster 4 is focused on advocacy. In this cluster the rehabilitation seems to polarise on the support of
knowledge development of people with disability. In fact the visual impairment could hinder the learning
process imposing behavioural limits. Hence the intervention is directed on young students with disability
supporting their learning as a way to emancipate them from disability. The professional role seems to be the
replacement of their client deficient ability, not taking into account the possibility to build his/her new abilities.
Nonetheless if substitution is the only support strategy, it could imply a high personal involvement for
professionals raising the risk of their burn out.
The variety of clusters’ distribution according with the professional role (fig. 3) suggests that each
group of practitioners represents differently the rehabilitation process. Physicians seem to focus particularly on
the management of the multidisciplinary team and the prevention of the visual impairment consequences (cluster
20
1 and 3). Instead, paramedical practitioners focus mostly on prevention (cluster 3). Anyway those two groups are
similar and have an unequal distribution of clusters, which highlight a specific perspective in looking at the
rehabilitation process, probably because they are trained in a medical context. The other two groups,
psychosocial workers and vision rehabilitation practitioners, show a more equal distribution, although vision
rehabilitation practitioners focus mostly on advocacy (cluster 4).
Fig. 3. Cluster distribution according to the professional role (VEDI TAB.2)
However, it is interesting to notice that no cluster word symbolizes the client with disability as active or
implied in the process. In fact cluster 1 and 2 do not show any word calling forth the client: in the first one the
target is the multidisciplinary team; in the second one it is absent. Moreover, even if in cluster 3 and 4 a client is
evoked, this is a child or a boy. Anyway no lemma reflects the implication of the adult with disability in the
rehabilitation process although every year more than half of the people undergoing the rehabilitation are adults
or young adults (see paragraph 2.1.). This absence is even more interesting considering that in the Italian
language the word adult calls forth the ability to discern and choose, connected with the maturation process of
the growth. This process characterizes differently every stage of life and is not specific only to adulthood.
Therefore the words child and boy could suggest a client who is symbolized as somebody lacking of something
and who is in need of development. In fact, the Italian culture often infantilizes the person with disability as if
he/she could never grow up. According to this, it is possible to make the hypothesis that participants represent
the adult with disability as passive, rather than actively implied in the rehabilitation process denying his/her
resources.
5. Conclusion
This study highlights a passive client representation not taking into account personal abilities or the
active participation to the process. Therefore it seems that the adult with disability is not represented as
independent, productive, self-effective or able in problem solving.
This representation does not help professionals to motivate their clients or help them to take an active
role. As mentioned in the introduction, to be effective, rehabilitation process needs the client’s collaboration in
taking responsibility for managing his/her own conditions and use rehabilitation practitioners’ support to develop
his/her abilities. For instance teaching to walk with the long cane does not imply that once rehabilitation process
is over the person with disability will use it to get out of his home. There is a difference between being trained
and using an acquired ability in everyday life.
21
Because of psychological difficulties people face to adapt to disability, it is up to professionals to
promote a change in their attitude. To achieve this goal, it is important for professionals to represent the person
with disability as able to state his needs and solve his problems. Therefore a passive representation does not help
professionals in being effective.
People passivity is not negative in all cases. Sometime it is important to rely upon professionals’ ability
to take care of somebody. For instance when it is not possible to act directly on the problem, as when it is
necessary to undergo a surgery. Passivity can solicit practitioners’ care and it is useful because intervention relies
upon professional performance. Nevertheless it is not useful in the rehabilitation process because it hinders the
possibility to motivate people in taking on an active role. In fact rehabilitation also relies upon people with
disability performance.
Moreover adults with disability often come to the Rehabilitation Service once the loss of their function
is so important that it limits their everyday life. More often they also encounter problems accepting this new
condition which implies the necessity to face not only practical strategies. In fact, part of the rehabilitation work
aims to help the person to face his/her new condition also from a psychological point of view. Nonetheless the
psychological treatment is a part of the rehabilitation process and is mainly provided by psychotherapists who
focus mostly on personal feelings related with the loss of sight. This implies that the psychological function
relies upon the analysis of the relationship between individuals and their disability. Nevertheless this study
suggests that it is possible to widen the psychological function working also on the client’s motivational process,
improving his/her commitment to the rehabilitation process. Since rehabilitation to be effective needs client
collaboration, it is up to the service to promote this process. Nevertheless the possibility to reach this goal
depends on professionals’ representation of their clients with disability. Therefore, psychologists could intervene
on the rehabilitation process to promote the client’s active participation, helping him/her in developing his/her
personal commitment to the treatment.
On the other hand an additional psychological contribution to rehabilitation process could consist in
helping professionals team to manage their relationship with the client, improving their effectiveness.
Thanks to the broad participation of professionals to this study it was possible to identify a factor that
influences service effectiveness of this specific context. Professionals’ representation of adult with disability is
an area in need of development. Work should be done to improve the rehabilitation service, helping
professionals to develop a more functional representation of their client, considering adult with disability as a
partner more than a patient.
This was a pilot study designed to explore the Rehabilitation Service of a single Centre and any broad
interpretation on other Centres could be made. Anyway, it would be interesting to extend the study to a broader
number of Centres to detect whether the passive representation of the client characterizes the Vision
Rehabilitation Service practitioners evaluating also its impact on service delivery.
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23
WhatsOnWeb: A Sonificated Search Engine for Blind
People
Mele M. L.1,2, Federici S.1,2, Borsci S.1
1
Department of Human Science and Education, University of Perugia; Perugia, Italy
ECoNA, Interuniversity Centre for Research on Cognitive Processing in Natural and Artificial Systems,
Sapienza University of Rome; Rome, Italy
2
Summary
In this work, we present the sonification procedure of a visual Web search engine called WhatsOnWeb
(WoW) and its usability evaluation. The WoW search engine is based on graphic visualisation algorithms
conveying datasets by semantic correlations and clusters through graph-drawing methods. WoW has been
developed combining different visual and auditory features in three sonificated layouts that transmit spatial
information through acoustic non-verbal events. WoW usability has been evaluated for both visual and
sonificated versions with blind and sighted users. Since results show no differences in usability, we conclude that
the sonification methodology makes visual content accessible, usable and, therefore, equally learnable for both
blind and sighted people.
Introduction
The first version of the web search engine, WhatsOnWeb (WoW) (DI GIACOMO et al., 2007; DI
GIACOMO et al., 2008), proposed to overcome the limitation of flat top-down spatial representation used by the
most common search engines, where the order of results does not take into account the quality of the information
conveyed (FEDERICI et al., 2008, 2010). In WoW, the indexed Web datasets are represented through graphdrawing methods based on sophisticated graphic visualisation algorithms through the use of semantic
correlations and clusters. As with most of the common search engines, WoW retrieves datasets by using the
PageRank algorithm (BRIN and PAGE, 1998) and represents them in a single page through a semantic network
of concepts and sub-concepts constituting an interactive spatial map. In this way, as graphical spatial
representation facilitates the information processing by semantic categorization (ANDERSON, 1993), WoW
overcomes the gap between the quantitative order and qualitative level of Web information that arises in most of
the flat top-down search engines. As it meets, supports and enhances the cognitive processes involved in the
interaction between user and interface, we define the geometrical spatial representation of WoW as a
psychotechnology which emulates, extends, amplifies or modifies the sensory-motor, psychological or cognitive
functions of the mind (FEDERICI et al., 2011; FEDERICI and SCHERER, 2012; MIESENBERGER,
CORRADI, and MELE, 2012).
In this work, we present a sonification procedure applied to WoW’s visual interface, i.e., an alternative
way to transmit spatial data through non-visual means. We followed a user centred design perspective (BORSCI
et al., 2013) to transform “data relations into perceived relations in an acoustic signal for the purposes of
facilitating communication or interpretation” (KRAMER et al., 1997, p. 3). We used the sonification
transformation model Action by Design Component (ADC; ZHAO, SHNEIDERMAN, and PLAISANT, 2007),
which transforms the visuo-spatial data output into a corresponding audio-spatial output. We evaluated the
differences between totally blind and sighted users’ experiences while they were respectively interacting with the
corresponding WoW sonificated or visual version of the search engine (MELE et al., 2012).
Materials & Method
Many studies highlight that the motion ability of blind users involved in spatial exploration guided only
by acoustic cues is functionally equivalent to the visually guided one (OLIVETTI BELARDINELLI et al.,
2009). This study aims to introduce a new way to convey web-indexed information by using a sonification
methodology. The user experience evaluation of both visual and sonificated WoW versions shows no differences
between blind and sighted people.
25
Participants. 8 participants (4 males; 4 blind users; mean age 28.2; standard deviation 5.9) took part to
the experiment. Blind subjects were selected in accordance with a diagnosis of either early or inherited
blindness.
Materials. The visual version of WoW is composed by a customisable layout. Users can choose
between three graphic configurations: radial (Figure 1.A), layered (Figure 1.B) and spiral TreeMap (Figure 1.C)
whose effectiveness and efficiency were previously evaluated (DI GIACOMO et al., 2007; DI GIACOMO et al.,
2008). The graphic structure of WoW is organised by semantic correlations among the indexed abstract
information. Navigation uses cluster nodes as semantic sets of results and leaf nodes representing a website or a
document. Both cluster and leaf nodes can be expanded or collapsed and, together, they form a single page
representation of all the indexed searched information (Figure 1). Nodes are related to each other by edges
representing their semantic relations.
Figure 1. WhatsOnWeb layouts: (A) radial; (B) layered; (C) spiral TreeMap
Design and procedure
1) Sonification. The sonification model Action by Design Component (ADC) provides users with a
dynamic interaction acoustic interface (ZHAO et al., 2007). We used the ADC model to design and test a
sonification layout of the accessible visual version of WoW presented in 2009 (MELE et al., 2009; RUGO et al.,
2009) to transmit the spatial and semantic information of graphical features and their combinations in an acoustic
non-verbal way. We applied the sonification process by combining visual and non-verbal acoustic features in a
univocal way. Table 1 shows three different sonification layouts developed by using different combinations of
tone, pitch, volume, blinking and grid reference with the z axis representing the spatial position of the graphic
objects of WoW, the web ranking of each node, the level of navigation and the type of node. We obtained three
different types of sonification layouts PanAndPitch, VolumeAndPitch and BlinkAndPitch.
26
Table 1: The three sonification layout prototypes of WhatsOnWeb
PanAndPitch
VolumeAndPitch
BlinkAndPitch
x Axis
Panning
Volume
Blinking
y Axis
Pitch
Pitch
Pitch
Ranking
Volume
Blinking
Volume
Level
Timbre
Timbre
Timbre
The three layouts can be navigated via the following steps: (i) after users press enter to execute their
query, a first global overview is displayed: this function corresponds to a temporisation technique (SAUE, 2000),
which transforms information from a non-temporal to a temporal (auditory) domain; ii) the navigation through
the graph of results is then translated into complex tones corresponding to the paraverbal information of clusters,
leaf nodes and their semantic relations (edges); iii) users orient their position throughout the interface thanks to a
reiterable feedback function providing the opening overall preview and a position signal that describes the
current position among the navigation steps; iv) verbal feedback voiced by an integrated synthesiser (or a
customised screen reader software) provides textual information by which users can identify and memorise data.
2) Evaluation. We conducted two kinds of user evaluations: (i) a heuristic evaluation and (ii) a user
experience evaluation (UX). (i) First, a heuristic evaluation conducted by three experts tested the usability of
each a sonification layout by using a readjustment of Nielsen’s heuristics (1994) to a simulated user scenario.
The results were applied to design a single layout composed by the best combination between the acoustic and
visual features, the PanAndPitchBlinking sonification layout (Table 2). The PanAndPitchBlinking sonification
layout conveys spatial information through the z-axis by means of the panning technique to represent the
position on the x-axis and the pitch feature to represent the position on the y-axis. Moreover, sound blinking
represents the rank order of each node.
Table 2: The PanAndPitchBlinking sonification layout of WhatsOnWeb
PanAndPitchBlinkin
x Axis
Panning
y Axis
Pitch
Ranking
Blinking
Level
Timbre
ii) The UX of the three Radial, Layered and Spiral TreeMap visual layouts and the
PanAndPitchBlinking sonificated layout were evaluated with blind and sighted users. The UX evaluation has
been evaluated by using the Partial Concurrent Thinking Aloud (PCTA) protocol (FEDERICI, BORSCI, and
MELE, 2010; FEDERICI, BORSCI, and STAMERRA, 2010) and the System Usability Scale (SUS)
questionnaire (BORSCI, FEDERICI, and LAURIOLA, 2009; BROOKE, 1996). After an exploration of the
layout lasting at least 3 minutes, users were asked to conduct an exhaustive WoW search by using the keyboard.
Results
Nineteen problems, 9 related to visual performance and 10 problems related to auditory performance
were found. No significant differences between blind and sighted users and between visual and auditory layouts
(Layered layout, F(1,6)=4.524; p>.05; Spiral TreeMap layout, F(1,6)=0.097; p>.05) were found, except for the
Radial layout (F(1,6)=13.690; p<0.05). The analysis of the SUS scores shows no significant differences
(F(1,6)=0.2729; p>.05) between blind and sighted subjects. A similar level of efficacy, efficiency and
satisfaction between blind and sighted groups and between the visual and sonificated information presentation,
highlights a functional homogeneity between sighted and blind UX users of WoW.
Conclusion
The way in which search engines represent and transmit information may hinder people with disabilities
to access and use web-indexed information (FEDERICI et al., 2008, 2010). This is particularly true for people
with visual disabilities, individuals who may face high accessibility problems in consulting web information
content (JAY et al., 2007) because of the flat top-down spatial ways in which search engines are commonly
organised. However, since we know that the cognitive representation of spatial information is independent of the
way in which sensory data are conveyed, other non-visuocentric ways to convey web information can be used.
For this reason, designing alternative sensory interfaces to transmit web content is a promising challenge to reach
the goal of universal access to web information (STEPHANIDIS, 2001).
In this work, we presented a sonificated version of WhatsOnWeb, a web search engine representing the
web-indexed information in a single page through a semantic network of concepts and sub-concepts constituting
27
an interactive spatial map. We described the sonification process of the visual display of WoW and the analysis
of the blind and sighted users experience while they respectively interacted with the sonificated and the visual
display of WoW. As no qualitative or quantitative differences between groups’ performances were found, data
confirm the functional correspondence between visual and auditory sensory information in spatial representation
(OLIVETTI BELARDINELLI et al., 2009). Therefore, this work highlights that organisation through semantic
categorisations facilitates the cognitive information processes that organises human knowledge (ANDERSON,
1993). As it supports and enhances the cognitive process involved in the interaction, independently from the
sensory way in which information is transmitted, WoW should be considered a psychotechnology emulating,
extending, amplifying or modifying the sensory-motor, psychological or cognitive functions of the mind
(FEDERICI et al., 2012).
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doi:10.1007/s10339-009-0268-9
BORSCI, Simone, KUROSU, Masaaki, FEDERICI, Stefano, and MELE, Maria Laura, Computer Systems
Experiences of Users with and without Disabilities: An Evaluation Guide for Professionals, Boca Raton,
FL, CRC Press, 2013.
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International World-Wide Web Conference: WWW ’98, Brisbane, AU, pp. 1-20, 1998.
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WEERDMEESTER, Bernard A., and MCCLELLAND, Ian L. (Eds.), Usability evaluation in industry,
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DI GIACOMO, Emilio, DIDIMO, Walter, GRILLI, Luca, and LIOTTA, Giuseppe, Graph Visualization
Techniques for Web Clustering Engines, IEEE Trans Vis Comput Graph, 2, 294-304, 2007.
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DI GIACOMO, Emilio, DIDIMO, Walter, GRILLI, Luca, LIOTTA, Giuseppe, and PALLADINO, Pietro,
WhatsOnWeb+: An Enhanced Visual Search Clustering Engine, IEEE Pacific Visualization Symposium:
PacificVIS ’08, Kyoto, Japan, pp. 167-174, 2008.
FEDERICI, Stefano, BORSCI, Simone, and MELE, Maria Laura, Usability evaluation with screen reader users:
A video presentation of the PCTA’s experimental setting and rules, Cogn Process, 3, 285-288, 2010.
doi:10.1007/s10339-010-0365-9
FEDERICI, Stefano, BORSCI, Simone, MELE, Maria Laura, and STAMERRA, Gianluca, Global Rank: tra
popolarità e qualità dei siti Web, Psicotech, 1, 7-23, 2008. doi:10.1400/113633
FEDERICI, Stefano, BORSCI, Simone, MELE, Maria Laura, and STAMERRA, Gianluca, Web Popularity: An
Illusory Perception of a Qualitative Order in Information, Univ Access Inf Soc, 4, 375-386, 2010.
doi:10.1007/s10209-009-0179-7
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reader users: Implementation of the Partial Concurrent Thinking Aloud technique, Cogn Process, 3, 263272, 2010. doi:10.1007/s10339-009-0347-y
FEDERICI, Stefano, CORRADI, Fabrizio, MELE, Maria Laura, and MIESENBERGER, Klaus, From cognitive
ergonomist to psychotechnologist: A new professional profile in a multidisciplinary team in a centre for
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29
Homophobia and Disability: Literature Review
Meloni F.1,2, Federici S.1,2, Mele M. L.1,2
1
Department of Human Science and Education, University of Perugia; Perugia, Italy.
ECoNA, Interuniversity Centre for Research on Cognitive Processing in Natural and Artificial Systems,
Sapienza University of Rome; Rome, Italy.
2
Summary
We conducted a literature review of 58 studies on homophobia and LGBT disabled people published
between 1994 and 2013 that reported a complex and conflictual relationship among different cultures. These are
the expression of three social communities: (i) the LGBT community, (ii) the disabled community, and (iii) the
mainstream society (mainly identified as the heterosexual and able-bodied community). The condition of
exclusion that both disabled and LGBT people endure is rooted in two socially shared myths: compulsory ablebodiedness and compulsory heterosexuality. Both of them are the basis of homophobic prejudice. However, in
order to neutralize the socio-cultural barriers, responses produced by the two minority communities, i.e., the
LGBT and disabled people, are often in conflict with each other making their spaces inhospitable to LGBT
disabled people.
Introduction
People with disabilities belong to a socially stigmatized minority group as well as LGBT people. When
people have more than one stigma, due to their belonging to more than one minority group, as in the case of
LGBT people with disability, they are part of a minority within a minority (BENNETT and COYLE, 2007). In
this particular condition the threats they face substantially increase, compromising their self-esteem and
psychological well-being (BENNETT et al., 2007; HIGGINS, 2010; MORGAN et al., 2011; SHAKESPEARE,
1999a). One of the most important barriers that LGBT disabled people have to deal with is the homophobic
beliefs of their relatives and caregivers (HINRICHS and VACHA-HAASE, 2010; LEBLANC and TULLY,
2001). We have conducted a literature review to investigate homophobia and disability in scientific research. The
study moves from an analysis of national (Italian) and international scientific production on the phenomenon of
homophobia related to LGBT disabled people.
Methods
Electronic databases (Medline, PsycINFO, PsycARTICLES and Google Scholar) were searched on
December 2013 for relevant books, chapters, and articles using the terms “homophob*” AND “disab*”in the “all
text” field query. Titles and abstracts (where available) were screened to determine eligibility. If there was doubt
as to the article’s eligibility, or the abstract was not available, the full-text was retrieved. Products were excluded
if: “homophobia” was only incidentally used and they did not refer to the living conditions of LGBT disabled
people.
Results
It was found that the term “homophobia” was used in 58 products belonging to the field of disability
study. Among them, 5 are books and book chapters (HALDEMAN, 2001; MAIL and LEAR, 2006; MCRUER,
2006a, b; TREMAIN, 1996), 52 are journal papers (ABBOTT and HOWARTH, 2007; BAROUNIS, 2009;
BLYTH and CARSON, 2007; BURNS and DAVIES, 2011; CAMBRIDGE, 1999; CORKER, 2001; DUKE,
2011; ELMAN, 2012; ERICKSON, 2007; FRALEY, MONA, and THEODORE, 2007; GRIEVE et al., 2009;
GROSSMAN, D’AUGELLI, and DRAGOWSKI, 2007; HAMILTON, 2009; HANJORGIRIS, RATH, and
O’NEILL, 2004; HASH and NETTING, 2009; HELLMAN and KLEIN, 2004; HENRY, FUERTH, and
FIGLIOZZI, 2010; HIGGINS, 2010; HINGSBURGER and TOUGH, 2002; HINRICHS et al., 2010; HUNT et
al., 2006; JOHNSON et al., 2005; KAFER, 2003; LANGLEY, 2001; LEBLANC et al., 2001; LIPTON, 2004;
LUCKSTED, 2004; MCCLELLAND et al., 2012; MORGAN et al., 2011; O’TOOLE, Corbett J. and BROWN,
2002; O’TOOLE, Corbett Joan and DOE, 2002; PARKES, 2006; PEATE, 2008; PERLIN, Michael L, 2013;
31
PERLIN, Michael L., 2011; ROBERTSON, 2003; SHAKESPEARE, 1999a, b; SINECKA, 2008; SMITH,
FOLEY, and CHANEY, 2008; STEVENS, 2012; STUART, 1994; SYKES, 2009; THOMPSON, 2003, 2008;
THOMPSON, BRYSON, and DE CASTELL, 2001; TROTTER, KERSHAW, and KNOTT, 2008; WALDEN,
2009; WATT et al., 2009; WEST, 2010; WITHERS et al., 2001; WOOD, 2004), and there was 1 abstract of
conference proceedings (FEDERICI, MELONI, and STELLA, 2012).
Among the 52 journal papers, 15 are quantitative or qualitative experimental studies and 37 are mainly
theoretical studies. The latter deal with or mention the term “homophobia” by framing it in major theoretical
perspectives on disability and LGBT studies: the social model of disability, queer theory, and feminist theories
(CHENG, 2009). The social and cultural background of the social model is the human rights movements of the
1960s. In 1975, the Union of the Physically Impaired Against Segregation claimed that “it is society which
disables physically impaired people. Disability is something imposed on top of our impairments by the way we
are unnecessarily isolated and excluded from full participation in society” (OLIVER, 1996, p. 22). Under this
theoretical lens, disability is considered as a form of socially constructed deviance; therefore, the disability
should have nothing to do with the body. Even the sexuality of disabled people is discriminated, since they are
perceived as unattractive and unfit to engage in relationships. Furthermore, the problem mainly concerns the role
of sexuality in the disabled identity: “Merging disabled identities with sexuality is problematic because only
predominant identities and sexual behaviors are seen as socially viable. […] only heterosexual identity and
sexual relations are viewed as possible” (CHENG, 2009, p. 114). The social perception of the body in the
construction of disabled identity is a big issue also within the feminist theories. Susan Wendell claims that
“Feminist theorists have probed the causes of our patriarchal culture’s desire for control of the body […]
Idealizing the body and wanting to control it go hand-in-hand […] In a culture which loves the idea that the body
can be controlled, those who cannot control their bodies are seen (and may see themselves) as failures.”
(WENDELL, 1989, p. 249). Homophobic attitudes and beliefs are a way to maintain the heterosexual and
masculinity hegemony within the orthodox patriarchal control of the body (BUTLER, 1990; CONNELL and
CONNELL, 2005). The theoretical reflection on the body is a key concept also for the queer theory. The queer
theory has conducted an in-depth study on the reasons of homophobia and heterosexism in our societies. In most
of them, two myths or values are widespread and shared underlying the exclusion of disabled and LGBT people
from the rest of society: the compulsory able-bodiedness (BAROUNIS, 2009; ELMAN, 2012; MCRUER,
2006a; SYKES, 2009; WEST, 2010) and the compulsory heterosexuality (MCRUER, 2006a; TREMAIN, 2000).
Alison Kafer explains compulsory heterosexuality as the desire of disabled people “to appear ‘normal,’ ‘natural,’
or ‘healthy’ in other aspects of their lives” (KAFER, 2003, p. 82) since they are oppressed and discriminated
because of their disability. The myth of compulsory heterosexuality is totalitarian: Every other non-heterosexual
behavior is considered abnormal and unhealthy. Tom Shakespeare says that “unlike groups who are oppressed
on the basis of ‘race’ or class, people who are disabled or gay may find that no one in their family, or local
community, shares their experience. There may be no role models or positive images” (SHAKESPEARE, 1999a,
p. 39). This leads the members of the two groups to share isolation and loneliness. As a consequence of the
prejudice they tackle “the route for many who are disabled or gay is to try and become invisible: to hide the
difference, or to ‘act straight,’ although this may be impossible for people with obvious impairments” (1999a, p.
39). However, there is another widespread myth in society: the asexuality of the people with disability
(HAMILTON, 2009; KIM, 2011; THOMPSON et al., 2001). Disabled people do not have sex and do not make
sex. In this way, the disabled LGBT has to face the fact of being a living oxymoron: If LGBT identities are
sexual identities and the disabled person is asexual, then the LGBT disabled person is conceptually impossible
(TREMAIN, 1996, 2000). The two communities try to overcome the social prejudices through the hyper
adherence of each of them to the respectively compatible social value: the LGBT community stressing the able
bodiedness myth until the so called “body fascism” (SHAKESPEARE, 1999a; WOOD, 2004) and the disabled
communities keeping at their border the non-heterosexual members. Actually, the LGBT disabled people are
hindered from living in any of the two communities.
The experimental studies focus mainly on the attitudes of health-care professionals and family
caregivers towards LGBT people with disability (ABBOTT et al., 2007; GRIEVE et al., 2009; HINRICHS et al.,
2010; PARKES, 2006). The most critical issues concern the lack of adequate training about love and sexuality
and a widespread moral condemnation of homosexuality. Because these attitudes are not always present at a
conscious level, caregivers often do not explicitly hamper sexual behavior, rather they do not provide proactive
support for sexual and emotional needs of LGBT disabled clients. As explored by Stefano Federici (2002) in
research on the sexual lives of disabled people in Italian residential centers, those that suffer most are
homosexual people with a disability living in institutions. Because of the need to implement training initiatives
to mitigate the effects of caregivers’ attitudes, Fabio Meloni and Federici (FEDERICI et al., 2012) developed
AmAAbili (Love-Able), the first Italian project of education and training on the issue of disability and sexuality.
AmAAbili was a research-intervention project divided into three parts: a data collection phase, an experiential
workshop phase and a 20-hour training course. Since 2011, based on the experience of AmAAbili, an annual 24
hours experiential training marathon for caregivers is organized on sexuality and disability.
32
Conclusions
The scientific literature on homophobic prejudice towards disability is still very limited and mainly of a
theoretical nature. There is a lack of experimental investigations on the spread of homophobic prejudice among
disable people and anti-disabled prejudice among LGBT people. At the same time, it is urgent that positive
action for education and training of social workers and caregivers is implemented so that they can provide
support to the sexual and emotional needs of their LGBT disabled clients.
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35
Attitudes and Perceptions of General Population
towards mental illness; drawing future mental health
services
Panayiotopoulos C.1, Pavlakis A.2
1
University of Nicosia, Dept. of Social Sciences (Cyprus)
Open University of Cyprus, Dept. of Health Management (Cyprus)
1
panagiotopoulos.c@unic.ac.cy
2
pavlakis@ouc.ac.cy
2
Abstract
Despite the magnitude of mental health problems worldwide, many cases of deinstitutionalization have
failed to achieve their targets for a number of reasons including lack of appropriate community psychiatric
services and lack of knowledge of new approaches. Aim: Therefore, the purpose of this study is to identify the
attitudes, beliefs, and mental health literacy of the general population toward mental illness. Methodology: The
Attitudes toward Severe Mental Illness (ASMI) scale was administered in the general population (n = 935) to
compare stereotypes and optimism with regard to mental health patients and their abilities to integrate into the
society. Results: The results indicate a general positive attitude that the general population holds towards mental
illness (M = 2.55, SD = 0.61).However questions revealed knowledge and previous experience indicated
contradictory results to the previous one. Participants’ answers to the source of knowledge as far as mental
health showed they had no immediate contact with mentally ill. Measurement of social openness and truthfulness
indicated a split in the sample. As far as guiltiness concern participants consider individuals with mental illness
as people who blame themselves for all bad things that happen in their lives. Educational level had a significant
impact (p<.004) on the attitude ‘’that mentally ill people are of a serious threat to our lives’’. Discussion: The
use of scales such as the ASMI not only makes it possible to map out attitudes and views but also to measure
individuals’ beliefs toward inclusion of these people. Results indicate that the core of the treatment needs to be
shifted from the medical compliance to the satisfaction of psycho-social needs of service users. Finally, targeted
educational programs referring to secondary education students and young adults may lead to lower rates of
social isolation and include more incidents of social integration.
Keywords: ASMI, attitudes, perceptions, mental illness.
Introduction
Mental health services are an important contributor in the provision of support toward mental health
patients. The design and development of mental health services’ structure and facilities are of vital importance.
Efficient design and development can enhance mental health services effectiveness. It thus becomes imperative
when, at the design stage or even when planning developments and improvement of mental health services, to
take into account the beliefs and attitudes of all stakeholders toward mental health patients—including those of
general population that can lead to social isolation or social integration of mentally ill persons.
Despite the magnitude of mental health problems worldwide, mental health policy and service
development seems not to be a priority for the majority of governments. Many cases of deinstitutionalization [1]
have failed to achieve their targets for a number of reasons including a lack of appropriate community
psychiatric services and a lack of targeted programs that fight discrimination and stigmatization of people with
mental illness. According to Link and Phelan’s [2] modified labeling theory, people who have been hospitalized
for mental illnesses may act less confidently and more defensively with others or may simply avoid a threatening
contact altogether. Consequently, mentally ill individuals may experience uncomfortable social interactions,
limited social networks, a deprived quality of life, low self-esteem, depressive symptoms, and loss of revenue
due to inability of finding appropriate work. As stigma places people at a substantial social disadvantage with
respect to these resources, it increases their exposure to risks and limits access to protective factors, potentially
adding to their burden of disease or disability [2].
37
As a country with recent efforts in regard to psychiatric reforms but without the development of a
coherent legislative framework, Cyprus is not an exception with regard to mental health stigma and its effects,
even though the number of patients being placed in the community is growing. Even so, these people remain
excluded, and in some cases they are not even aware of their rights [3].
Therefore, the aim of this study is to identify the attitudes, beliefs, and mental health literacy of the
general population toward mental illness as a tool for developing mental health services targeting all those
parameters previously discussed. This process is imperative as a first step to explain the high numbers of
mentally ill people living as outcasts even today and secondly to secure their future in the community. To
accomplish this task, we administered the Attitudes toward Severe Mental Illness (ASMI) scale [4] to the general
population to identify stereotypes and optimism with regard to mental health patients and their abilities to
integrate into the society.
Mental Health Illiteracy among the General Population as a Tool for Developing
Effective Mental Health Services.
Many members of the public cannot correctly identify mental disorders and tend not to understand
clearly the meanings of associated psychiatric issues [5]. The rationale behind the need for the public to become
mental health literate is highlighted. In particular, this need for mental health knowledge is reinforced by the
high life-time prevalence of mental disorders that goes up to 48 percent [6]. This percentage means that virtually
one in two individuals will either develop a mental health disorder or be in contact with someone who does. Due
to this lack of knowledge and the influence of stereotypes in media, the general public tends to view the mentally
ill as unpredictable, responsible for their bizarre beliefs and behavior, incapable of rational thought, and probably
dangerous. When these stigmatizing beliefs filter through society at many levels, it is no surprise that the
mentally ill often find themselves socially excluded and isolated. All these factors lead Jorm, Korten, Jacomb,
Christensen, Rodgers, and Pollitt [7] to introduce the term mental health literacy. Mental health literacy
incorporates components of the knowledge and beliefs about mental disorders that aid their recognition,
management and prevention.
It becomes obvious that mental health illiteracy may lead to social exclusion and isolation of people
with mental health disorders. In the same way it may also cause problems of communication between mental
health patients and practitioners who are mental health illiterate. Moreover, family and friends of mental health
patients might prove more helpful in administering or supporting treatment to their mentally ill family members
than those who are ignorant of what a mental illness is. [8]
Can then someone argue that raising-awareness campaigns will decrease the severity of the problem to
the point that mental health literacy will rise significantly enough to build up a healthier environment for
mentally ill people? An answer to this question is given by Crisp, Gelder, Rix, Meltzer, and Rowlands [9] who
indicated that although stigmatizing attitudes toward people with mental health disorders are widely held in the
general public, a campaign against stigma needs to do more than provide information about mental disorders. It
should also attempt to reduce discrimination. We argue that a campaign should enclose not only scientific
information about symptomatology, medical treatment and relapse signs. It should also provide a holistic
understanding (psycho-social, economic, medical aspects of the illness) on how to approach this vulnerable
group of people, how to include them in the wider social context in which we live and work, and how to improve
the abilities and skills of these people as far as day-to-day life is concerned.
It is therefore important, especially for planning and designing effective services to understand the
attitudes and knowledge of the general public toward individuals with mental illness. Based on the findings of
this study, mental health services can overcome gaps in service provision and also can address issues associated
with barriers toward the inclusion of mentally ill people while they are in the phase of rehabilitation. We expect,
based on our findings, that we can make recommendations on how to alleviate the stigma and prejudices for both
groups by mapping their attitudes and mental health literacy.
Methodology
As argued previously, this study explores the views and the knowledge of mental health professionals
and the general population toward mental illness.
Data were collected through the means of two questionnaires. Questionnaire 1 used in this study had
two parts. In the first part, participants (n = 935) indicated their demographic characteristics including, age, sex,
marital status, education, and family income. Participants were also asked to report their health status using a
five-point Likert scale from1 (very good) to 5 (very bad). In the second part, participants were asked to indicate
their attitudes toward severe mental illness. To measure participants’ attitudes toward mental illness, we used the
Attitudes towards Severe Mental Illness (ASMI) scale 3.
38
This particular scale, which was used as a guide for the Opinions on Mental Illness [10] scale developed
by Professor Madianos in Greece and it was validated in Athens in a study (n = 2,370) among the general
population, health and mental health professionals, and users of mental health services. Questionnaire 2 explored
the depth of knowledge of mental illness and treatment methods. In particular, participants were asked to identify
types of severe psychiatric disorders (i.e., schizophrenia, depression, postnatal depression, anxiety related
disorders, personality disorders), causes of a mental health problem, and possible methods to help those people.
There were also questions about previous knowledge with mental illness either due to a personal experience or
due to a family/relative case. It was administered to the general population (n = 935) group in this study.
The ASMI scale has been found to be reliable (0.89 for factor D and 0.92 for factor A subscales) and
valid. It consists of 30 questions, the great majority of which are rated in a following five-point Likert scale. For
the rest of the questions the reverse scale is used.
The ASMI measures four factors related to attitudes toward mental illness: Stereotyping, Optimism,
Social Openness, and Guiltiness. Stereotyping is defined in terms of distinguishing stereotypes of devaluations of
persons suffering from severe mental illness. The persons who are suffering from such disorders are described as
inferior to the “normal population, while an implicit suggestion of the necessity to be dependent on medication is
included. A higher score indicates less stereotyping. Optimism shows a profile of items close to the clinical
reality with a positive view toward the competences of a person suffering from serious mental illness;
accordingly, the items of this factor imply a sense of optimism. In this case, a higher score indicates more
optimism that the patient will be self-sufficient despite his or her illness. Social Openness consists of a set of
items that are characterized by the need to encourage a person with a serious mental disorder to participate in
various social activities, to avoid isolation, and to seek treatment. A higher score indicates more openness.
Finally, in Guiltiness the central idea is that persons with serious mental illness feel guilty for their problems. It
incorporates a notion of scapegoating because others blame the suffering person. In this case, higher means
indicate less guiltiness.
More specifically, this part consists of questions asking participants to identify psychiatric disorders,
causes of a mental health problem and possible methods of helping these people. There were also questions
about previous knowledge with mental illness either due to a personal experience or due to a family/relative
case.
Sample
The ASMI was administered to a representative sample of the general population (n = 935) across the
island. Research data were collected by telephone interview. The method of telephone interview was used to
examine the attitudes of the general public toward mental illness. This method was selected because it is an
inexpensive, reliable, and valid tool for collecting behavioral data [11]. Moreover, the anonymity provided by
the telephone interview evokes more honest answers. In the beginning of the interview participants had to give a
verbal consent that they were willing to participate in survey on mental health attitudes. The interview lasted
approximately 20 minutes. The participants (n = 935) were selected using the random stratified sampling method
from a population of individual who were 18 years old or older and their names were included in the telephone
directory. The general population was administered Questionnaires 1 and 2, and the response rate was 86
percent.
Results
The second group in this study was the general population and we collected data on their attitudes,
views towards mental health patients and the levels of their mental health literacy through Questionnaires 1 and
2. Overall, 935 Greek Cypriots took part (440 men and 495 women). Of 1,045 telephone recorded calls, 935
successful interviews were completed; 111 (14%) refused to participate in the study. The response rate is
estimated at 86 percent; 47.2 percent of the sample were men and 52.8 percent were women. The mean age of
participants was 47.79 (SD = 16.96). Moreover, 75.6 percent of the participants were married, 17.1 percent were
single, 4.3 percent were widowed, and 2.7 percent were divorced. Finally, 43.1 percent of the participants had
completed a secondary education, 35.7 percent had completed a university education, and 21.3 percent had
completed a primary school education or had no schooling.
Four composites were computed by summing the items for each factor. Each composite was divided by
the number of items that composed it, and means and standard deviations were computed. The no opinion data
points, constituting less than 1 percent of the answers, were removed from this analysis.
A series of ANCOVAs was performed on each composite with the level of education, participants’ sex,
and personal income as the independent factors. Because we would like to know whether experience with
mentally ill people has an influence on attitudes, we also enter the participants’ scores on the questions “Over the
last few years have you met any mentally ill individual?” and “Have you visited a patient in an institution for the
39
mentally ill?” as independent variables. For each composite, we dropped the factor that was less significant and
we rerun the ANCOVA test. This process was repeated until we reached a model where all independent factors
become significant.
For Optimism and Openness no significant effects were found. However, there is a significant main
effect of educational level on Stereotyping, F(2,460) = 23.27, p < 0.001, p2 = 0.092. Post hoc comparisons
(Bonferroni) indicate that those who have a university degree hold less negative stereotypes (M = 2.77, SD =
0.53) from those who have only finished high school (M = 2.62, SD = 0.55) and those who have finished only
primary school or they did not go to school at all (M = 2.05, SD = 0.55). Furthermore, the age factor was
significant, F(1,460) = 27.34, p < 0.001, ηp2 = 0.056, with a negative coefficient on age (–0.010) indicating that
as people are getting older they become more likely to hold negative stereotypes.
The results indicate a significant main effect of educational level on Guiltiness, F(2,507) = 3.72, p =
0.025, ηp2 = 0.014. Post hoc comparisons (Bonferroni) indicate that those who hold a university degree see the
mentally ill as feeling guiltier for their problem (M = 1.76, SD = 0.61) than those who have only finished high
school (M = 1.93, SD = 0.65) and those who have finished only primary school or did not go to school at all (M
= 1.99, SD = 0.64). Finally, in all four analyses no significant interactions were produced.
Discussion.
Interestingly, our findings demonstrate that the general population holds a relatively more positive
attitude toward the particular group of people than what we expected too. In particular those results imply that
the general population expresses less negative stereotypes and is more optimistic about the future of these
people. Reading through the data someone might think that Cyprus is an open society where the general
population is more accepting and supporting toward this group of people. Is the situation as indicated by the data
analysis? When public was asked to refer to any source of mental health knowledge, only a small percentage of
those mentioned personal experience (family member, friend, or themselves) or high level of mental health
literacy. It seemed clear that they were more positive mainly due to their mental health illiteracy and due to their
ignorance toward the real needs of those people who are still partially isolated in our society. The way to
overcome this confusion may be contact with individuals who have mental illnesses and targeted education [11,
12] preferably at early stages of human’s life (15–18 years old) with respect to the medial, social, and
psychological aspects of psychiatric disorders may decrease levels of stigmatization and positively affect
attitudes and improve mental health among the general population.
However it is important to take in consideration the cultural context in which this study took place. This
culture does not necessarily coincide with the optimism and lack of stereotypes that were found from the data
analysis of the general population. In particular anecdotal evidence based on the legal framework but also a
recent report [13] on the alternatives mental health patients might have with regard to work indicated serious
difficulties and barriers to vocational rehabilitation. More specifically, internal (mental health professionals) and
external barriers (lack of interest from candidate employers) to the mental health system were causing serious
problems on the integration of mental health patients into the labor market.
Targeted educational programs and strategies [13] implemented throughout secondary education and
then at an adult stage and continuous promotion and campaigns on important issues such as types of psychiatric
disorders, the effects and methods of support to mental health patients may lead to lower rates of social isolation
and more incidents of social integration.
References
1. Ministry of Health and Social Cohesion. (2010). Evaluation report of interventions during the implementation
of psychiatric reform for the period 2000–2009. Athens, Greece.
2. Link, B.G., & Phelan, J.C. (2006). Stigma and its public health implications. Lancet, 367(9509), 528–529.
3. Panayiotopoulos, C.; Amitsis, G.; & Stathakopoulou, E. (2009) Evaluation of a vocational rehabilitation unit.
Nicosia, Cyprus:Ministry of Health, Mental Health Services.
4. Madianos, M.; Economou, M.; Kallergis, G.; Allevisopoulos, G.; & Rogakou, E. (in press) Stigmatising
opinions about severe mental illness? Can they be measured? A study among general population, health
and mental health professionals and users of mental health services. Social Psychiatry and Psychiatric
Epidemiology.
5. Jorm, A.F. (2000) Mental health literacy:Public knowledge and beliefs about mental disorders. British Journal
of Psychiatry, 177(5), 396–401.
6. World Health Organisation. (2004) The world health report 2004. Changing history. Geneva.
40
7. Jorm, A.F.; Korten, A.E.; Jacomb, P.A.; Christensen, H.; Rodgers, B.; & Pollitt, P. (1997) “Mental health
literacy”:A survey of the public’s ability to recognize
8. Panayiotopoulos, C., Pavlakis, A and Apostolou, M (2013) “Improving mental health services through the
measurement of attitudes and knowledge of mental health professionals and the general population in
Cyprus,” International Journal of Mental Health, vol. 41, no. 4 (Winter 2012–2013), pp. 29–46.
9. Crisp, A.; Gelder, M.G.; Rix, S.; Meltzer, H.I.; & Rowlands, O.J. (2000). Stigmatisation of people with mental
illnesses British Journal of Psychiatry, 177(1), 4–7.
10. Link, B.G., & Phelan, J.C. (2001) Conceptualizing stigma. Annual Review Sociology, 27, 363–385.
11.Esters, I.; Cooker, P.; & Ittenbach, R. (1998) Effects of a unit of instruction in mental health on rural
adolescents’ conceptions of mental illness and attitudes about seeking help. Adolescence, 33(130), 469–
476.
12.Hugo, M. (2001) Mental health professionals’ attitudes toward people who have experienced a mental health
disorder. Journal of Psychiatric and Mental Health Nursing, 8(5)
13. Poliniki, A. (2011) Attitudes of general health practitioners and the general public towards severe
psychiatric disorders in Cyprus. Unpublished thesis. Open University of Cyprus, Nicosia.
41
Autonomic Nervous System reactivity, emotion and
stress response in psychopathology.
Pruneti C.1, Cosentin, C.1, Fontana F.2
1
2
Department of Clinical and Experimental Medicine, Clinical Psychology Unit, University of Parma (Italy)
Faculty of Psychology, University of Bologna (Italy)
Abstract
Eighty nine subjects were consecutively examined into an outpatient Clinical Centre. According to
DSM IV-TR criteria they were diagnosed as: Generalised Anxiety Disorder (GAD), Major Depressive Episode
(MDE), Panic Attack Disorder (PAD), Obsessive Compulsive Disorder (OCD) Anorexia Nervosa (AN). All
individuals underwent a continuous and simultaneous registration of four physiological parameters strictly
connected with the autonomic arousal: Skin Conductance Response (SCR), Heart Rate (HR), Inter Beat Interval
(IBI), Peripheral Temperature (PT) Electromyography of the Frontal Muscle (EMG). All parameters were
continuously registered in three consecutive phases: Baseline, Stress and Recovery. Collected data from the four
groups of individuals were using the means value of the last minute of Baseline, and two activation indexes:
“Stress Response” and “Recovery after Stress”.
Results confirm the relevance of the psychophysiological evaluation in the multidimensional diagnosis
in clinical psychology and psychopathology. Furthermore, obtained data suggest the hypothesis of a new tool
for differential diagnosis, the specific and typical pattern of Autonomic Response for some psychopathological
syndromes.
Key words: psychophysiology, autonomic arousal, differential diagnosis, psychopathology
Introduction
Diagnosing is a complex procedure for mental health practitioners. DSM IV-TR and ICD -10 are useful
guides but can’t be the only one clinical diagnostic support. The multidimensional approach to clinical diagnosis
in psychopathology aims to the collection of relevant clinical information from different areas as the behavioral,
the cognitive-emotional and the psychophysiological to better individuate and describe the pathological
phenomenon. Specifically, the psychophysiological evaluation, is the detection, storage and evaluation of
physiological indexes connected with the Autonomic Nervous System (ANS) arousal and with the complex
system of stress response. The most detected indexes are the Peripheral Temperature (PT), the Galvanic Skin
Response (GSR), in particular the Skin Conductance Level (SCL) and Response (SCR), the Hearth Rate (HR),
the Inter Beat Interval (IBI) and the Frontal Muscle Tension, through Electromyography (EMG). There are
many scientific evidences coming from experimental and clinical studies regarding the relevance of these
indexes in the psychopathological manifestation. The works of Grey (Grey, 1978) and Fowels (Fowels, 1980,
1988) demonstrate that HR and SCR increase is the most important physiological correlate of the Behavioral
Activation System (BAS), able to regulate the appetitive behaviors and part of the fight or flight reactions.
Instead, the Behavioral Inhibition System (BIS), is characterized by HR and SCR decrease, and is able
to mediate the conflicts connected with the approach to problematic situation.
Thus in order to evaluate the Autonomic Arousal, the most used tool is the Psycho Physiological Profile
(PPP) firstly described by Fuller (1979). The PPP requires the simultaneous registration of the physiological
parameters connected whit the Autonomic Stress Response. Most used stressors are the Mental Arithmetic Task
(MAT) or problem solving tasks as the CPM 47 in computerized version (Sanavio & Bettinardi, 1984; Pruneti,
1995). The PPP evaluation aims to verify if there is a psychophysiological imbalance as:





High value of some parameters at B, sign of an improper autonomic activation; .
Slow, inconstant, or absent steadily pattern of one or more parameters at B;
Abnormal amplitude of S activation in one ore more parameters;
Slow, inconstant or absent modification of one or more values at S;
Slow inconstant or absent tendency to return to the baseline values at R.
43
Many studies showed the possibility to describe specific physiological pattern related to some
psychopathological syndromes. Stegagno & Palomba (1994), found typical physiological patterns in Depression
and Anxiety. Specifically, Anxiety was connected with high level in HR, SCL, EMG, and low values in PT;
Depression, instead, showed low or irregular HR and EMG, and low level of SCR both at rest and during the
stress session. Low level of SCR at rest in depressed patients were massively described in literature (Argyle,
1991; Pruneti et al., 2000; Wilhem et al., 2001). A hyper activated pattern was also found in patients with Panic
Attack Disorders, PAD (Hoehn, 1991), especially in SCR at rest (Hoehn et al., 1997;Dractu & Bond, 1998;
Parente et al., 2005).
Also in patients with Obsessive Compulsive Disorder (OCD), a pattern characterized by low and cyclic
level of autonomic arousal at Baseline with reduction of the SCR, EMG and HR was described (Lelliot et al.,
1987; Hoehn et al., 1995).
The principal aim of the present study is to verify, using PPP parameters EMG, SCR, HR, PT, the
presence of these typical patterns of ANS arousal in five psychopathological subgroups with Anxiety,
Depression, Panic Attack, Obsessive Compulsive Disorder and Anorexia and a control group of healthy people.
Materials and method
1.1 Sample
A group of 89 people, 44 male and 45 female, aged between 21-51 (mean age 38.4 ± 9.7) was
consecutively recruited in a Clinical Psychology Center with the following diagnosis according to the DSM IV –
TR, not ta:





General Anxiety Disorder (GAD =35);
Major Depressive Episode (MDE=13);
Panic Attack Disorder (PAD =9);
Obsessive Compulsive Disorder (OCD=13);
Anorexia Nervosa restricted (AN=9).
A group of 34 graduate and doctoral student of psychology, 20 female, 14 male, aged between 21-34
(mean age 23.27 ± 3,22), was recruited as a control group once verified they weren’t undergoing psychological
or pharmacological treatment or had done some of this in the past.
Patients of all the selected psychopathological groups were not taking any psycho drugs at the time and
in the past three months. Furthermore, individuals affected by other physical illnesses connected with the CNS or
with concomitant organic syndromes or with co morbidity with other Axis I disorders of the DSM IV –TR were
excluded.
1.2 Procedure
All subjects underwent a continuous physiological registration of 4 psychophysiological parameters
(EMG, SCR, THE, HR), divided as follow:
Adaptation phase: Participants were welcomed in a temperature and humidity controlled room
(between 18 to 22 C° and below 55% humidity). Two clinical psychologists gave all the explanation regarding
equipment, the electrodes and the other devices, granting the procedure as non painful.
Baseline registration (6min): subjects were asked to close their hays and to be calm and relaxed
Stress registration (4 min): subjects were asked to perform the Mental Arithmetic Task (MAT) as a
Mental Stress Test (MST).
Recovery registration (6 min): subjects were asked to stop the exercise and try to relax and rest.
The device used was the “Modulab 800” by SATEM, Rome, Italy, facet with a PC and data were
detected and processed by the PANDA Works Program Software (by SATEM, Rome, Italy).
1.3 Statistical analysis
For all the physiological parameters Mean and Standard Deviation of three indexes were calculated:
 Last minute of baseline;
 First minute of the stress phase, to evaluate the highest activation during the MST presentation, excluding
habituation;
 Last minute of the recovery, as a evaluation of the best possible recovery after the stress presentation.
The statistical test of Shapiro-Wilks was utilized to evaluate the normal distribution of the values; being
not normal in the distribution a non-parametric statistical analysis was computed.
44
The Mann-Withney statistical test was utilized to verify the significance of the differences between
groups.
In order to better describe the performance of the registered values in the three phases , the following
indexes were also calculated:
Stress response; as a index of the autonomic activation response amplitude, subtracting from the mean
value of the first minute of the stress phase the mean value of the last minute of baseline session.
Recovery after stress; to evaluate the recovery amplitude after the best activation, subtracting from the
mean value of the all stress session the mean value of the last minute of the recovery phase.
Results
EMG values comparison at rest and during the stress session, shown a significant statistical difference
between control and pathological groups. Patients with PAD, GAD, OCD, MDE and AN seems to be
characterized by a higher level in muscle tension than healthy (Tab. 1, Fig.1).
In the SCR- SCL values comparison some statistical significant differences were found in all the phases
(Tab. 1, Fig. 1)
.
Figure 1: EMG and SCR values at Baseline (B), Stress (S) and Recovery (R) for each subgroup
Furthermore, GAD and PAD are characterized by higher values in SCR in all the three phases in
comparison to MDE, OCD, AN and Healthy. MDE and AN showed a typical pattern of a very low values in the
same parameter in all the three phases.
The comparison between groups regarding the HR parameter showed a typical pattern of high value in
all the phases in GAD patients so different to the other psychopathological groups and to the healthy (Tab. 1,
Fig.2)
45
Figure 2: THE and HR values at Baseline (B), Stress (S) and Recovery (R) for each subgroup
AN showed a low level of muscle activation in comparison of the others and the MST response was
significantly lower than PAD, OCD, MDE. Furthermore, GAD, OCD and PAD seem to have a similar pattern,
differently from MDE and AN in particular for the SCR parameter (Fig.1), with the most significant difference
among AN and GAD groups.
Discussion and Conclusion
These results seem to confirm some literature data giving more specific indications for every
psychopathology (Pruneti et al., 1999; Pruneti et al., 2002). A condition of autonomic hyper activation is
typically connected to high levels of tension and anxiety, while a low level of autonomic activation and the
impossibility to react to the stimuli is typically connected to MDE and OCD. As hypothesized by Fowles and
Gray (Gray, 1978; Fowles, 1980; Fowles, 1988), the most relevant physiological indexes seem to be the SCL
and the HR,.
Furthermore, baseline HR, resulting higher in GAD than PAD patients could be a differential index
between syndromes manifestations.
The GSR trend of GAD, PAD and MDE, seems to confirm the Gray and Fowles BIS and BAS theory:
high values in baseline, a values pick during the stress presentation and the incomplete recovery could be
connected to the BIS system. Basing on this data, Roth, Wilhem and Trabert (1998) suggest that PAD low level
of relaxation capability, suggested also by excessive spontaneous fluctuation and absence of recovery in SCL
parameter, could be connected to the continuous high level of attention on the body and to the mental sensations
trying to control anxiety and tension. Similarly, SCL pattern in GAD patients could reflect the BIS activation
linked to anticipatory anxiety and performance anxiety. In the GAD patients the high HR level at rest could
represent the BAS activation associated to worry and apprehension even at rest. Conversely, in MDE patients a
sort of malfunctioning of BIS, with low and steady SCL level, that could be a helplessness physiological
correlate (Seligman et al., 1979), with a life style being more and more poor with a maladaptive feedback on the
autonomic system.
Results of this work, foster a better description of clinical psychopathologies in order to implement
pharmacological and psychological therapies properly individualized and integrated. A multi-dimensional
diagnosis through different and objective parameters, could surely give a strong help in order to avoid over
treatments and to diminish the risk of relapses, thus increasing treatments compliance.
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Fuller G.D. (1979). Biofeedback Methods and Procedures in Clinical Practice. S. Francisco: Biofeedback
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Gray J.A. (1978). The neuropsychology of anxiety. British Journal of Psychology, 69: 417-438.
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Raven. Bollettino di Psicologia Applicata, 210, 41-47.
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47
Selected treatment strategies for emotional and
behavioural disorders in children and adolescents
Samuel E.
Associate Professor of Psychology
Crandall University
Moncton, NB, Canada
edith.samuel@crandallu.ca
Abstract
This review looks at selected effective treatment strategies for emotional and behavioural disorders in
children and adolescents. Theories of mentalization, intentionality, attachment, the consolidated framework for
implementation research, and reasoned action are used as explanatory tools to conceptually situate these
disorders. This descriptive analysis, gleaned from secondary sources, focuses on four major types of intervention
strategies namely, cognitive behaviour therapy, family-based programs, psychopharmacological therapy, and
multisystemic therapy. The review concludes that all four strategies, customized to suit specific cases, are
relevant to effectively treat emotional and behavioural disorders in children and adolescents.
Key words: treatment strategies, emotional disorders, behavioural disorders, children, adolescents
Introduction
Emotional and behavioural disorders (EBD) may be organized into two types: externalized behaviours
and internalized behaviours (Kauffman & Landrum, 2013). Externalized behaviours in children and adolescents
are those that are antisocial, impulsive, aggressive, disruptive, destructive, and in breach of the rules and
regulations of society. Internalized behaviours include mood disorders (e.g. depression), anxiety disorders such
as posttraumatic stress disorder, and psychiatric disorders (e.g. schizophrenia). Diagnosis and treatment for these
disorders are imperative, necessary, and critical.
1.
Prevalence
Current epidemiologic investigations in Canada, the US, and the UK suggest that 14% of children
between the ages of 4 and 7 years have some form of emotional and behavioural disorder at some specified
period of time (Waddell, McEwan, Shepherd, Offord, & Hua, 2005). Generally speaking in the U. S., at least a
quarter of youths, at some time or other, are diagnosed with some form of mental disorder (Merikangas,
Nakamura, & Kessler, 2009), In Canada alone, about one-fifths of children experience some form of EBD; and
yet, less than a quarter of them receive any type of specialized care (Kutcher, 2011).
The prevalence of psychiatric disorders around the world amount to about 8.3% for preschoolers, 12.2%
for preadolescents and 15% for adolescents (Roberts, Atkinson & Rosenblatt, 1998). The incidence rates are
comparable to North American and Western European countries with the exception of Italy, Australia, Hong
Kong, and China where the rates are somewhat lower. Prevalence rates in Eastern Europe are slightly higher. As
well, emotional disorders rates are found to be higher among girls and behavioural disorders higher in boys,
although it is common for some children to have both (Walker & Melvin, 2011).
2.
Theoretical Framework
Theories of mentalization, intentionality, attachment, and the consolidated framework for
implementation research, and reasoned action are used as explanatory tools to frame emotional and behavioural
disorders in children and adolescents. It was in the late 1960s that mentalization theory was initiated by
psychoanalysts in France. This framework has been used today in the studies of cognitive therapy in behavioural
disorders (Soderstrom & Skarderud, 2009). The theory of mentalization focuses on the ability to visualize
cognitive situations in oneself and others and to comprehend behaviour with reference to mental ability. Mental
states refer to all types of cognitive experiences such as beliefs, desires, intentions, thoughts, and feelings.
Mentalization therefore encompasses the aptitude to recognize and decipher one’s own as well as others’
49
emotional states or reflective functioning. The process is closely associated with ‘affect regulation’ or having
the capacity to understand and control one’s physiological and emotional stimuli. A lack of mentalizing skills
may lead to misinterpretations, misapprehensions, and misconceptions in social interactions. This theory
connects favourably with the implementation of cognitive behaviour therapy in treating emotional and
behavioural disorders in children.
The intentionality model (Owen, 2009) acknowledges that interventions and strategies are ways to
change the meaning of events that take place in individuals’ lives. According to this model, emotional and
behavioural disorders are made up of conscious ways in which the individual understands problems differently.
A tradition that comes from Edmund Husserl (1999), intentionality emphasizes the notion that the individual
subjectively comprehends a conscious experience. This phenomenological view relates to purposeful behaviour
towards aspects of life and others including empathy, mood, and attachment. Intentionality helps in being aware
of one’s psychological disorder, and an understanding of one’s self, personality, and behaviour. This model
forms a basis of cognitive-behavioural therapy where relevant questions regarding the disorder are asked. These
questions relate to the beginning, duration, and aftermath of the conditions, and focus on the sequence of
intentionalities that underlie any type of behavioural disorder. This model vividly illustrates the client’s
experience and theoretically situates any type of therapeutic action.
Attachment theory (Ainsworth & Bowlby, 1991) is based on the child’s libidinal tie (Freud, 1905/1953)
to the mother’s bonding with the infant and vice versa. This connection transpires during the first year of the
infant’s life in the form of sucking, clinging, smiling, and crying leading to degrees of attachment. A positive
family microculture is vital to the growth and evolution of mother-child attachment. Attachments may be
ambivalent (unsure), avoidant (ignoring) or secure (protected) depending on the level and type of attachment
developed between the child and mother. When a mother abandons or rejects a child, such a response may lead
to separation anxiety. These anxieties within the child may play a part in the aggravation and exacerbation of
emotional and behavioural disorders. This theory ties in favourably with family functional therapy, a problemsolving aspect of treatment.
The Consolidated Framework For Implementation research (CFIR) delineates constructs into five main
domains necessary for effective treatment programs: a) intervention characteristics, b) outer setting, c) inner
setting, d) individuals involved, and e) the implementation process (Damschroder & Hagedorn, 2011).
Intervention characteristics consist of evidence in the rigour and value, comparative benefit, flexibility, intricacy,
strategy, and expense of the programmes. Outer setting refers to client desires and assets, cohort tensions,
exterior plans, and inducements. Inner settings are ascribed to networks, communication, culture, climate, and
readiness for implementation. Characteristics of individuals comprise the knowledge they have about the
treatment itself, their abilities to adapt, the stages of change they find themselves in, and their association with
the organizations. The procedure in implementation consists of planning, executing, reflecting, and evaluation of
the programmes. This framework is suitable to interpret psychopharmacological and multisystemic types of
interventions.
Closely connected to the above models is the theory of reasoned behaviour (Ajzen & Fishbein, 1970).
This theory argues that a person’s behaviour can be foreseen by attitudes maintained toward the behaviour,
subjective norms pertaining to the behaviour as well as the intention to carry out that behaviour. Attitudes reflect
the positive or negative evaluation of engaging in a particular type of behaviour. Subjective norms mirror
apparent social stresses to implement specific behaviours that stem from various personal (e.g. family,
physicians) or environmental (e.g. media) sources. Perceived behaviour control exposes the extent to which
behaviour is volitional and is thought to indirectly affect behaviour through intention and direct influence.
Positive attitudes, affirmative subjective norms, and optimistic control are required tools to make interventions
effective, and valuable in emotional and behavioural disorders in children and adolescents.
3.
Method
This study is based on secondary research studies completed on four treatment key strategies that could
prove to be significant and decisive in providing treatment for children with EBD. Research was drawn from
reputed and prestigious psychology journals and reviewed. These journal articles were then looked at in-depth
and analyzed thematically under the four categories, they being 1) cognitive behaviour therapy, 2) family-based
programs, 3) psychopharmacological disorders and 4) multisystemic approaches. These key strategies have been
selected, described, and critically looked at among several others, since they are primarily and predominantly
used in treating the various emotional and behavioural disorders in children and adolescents.
50
4.
Findings
4.1. Cognitive behaviour therapy
The real meaning of the cognitive behaviour therapy (CBT) approach is the notion that behavioural
responses to the environment are interceded by the thoughts or thinking of an individual. Thus, imparting more
useful or constructive ways of thinking about one’s environment can positively influence the way an individual
behaves within or toward it. Exercises like self-talk, self-evaluation, problem-solving, and self-instruction all
stem from this approach and are used largely as therapeutic interventions with children and adolescents who
experience anxiety and mood disorders (van Starrenberg et al., 2013).
4.1.2 Cognitive behaviour therapy and conduct disorder
Cognitive-behavioural therapy focuses primarily on thought processes and utilizes behavioural
techniques to change those processes that are seen as being responsible for the defiant demeanour. The therapist
tries to involve the client in novel ways of thinking that will result in intuitive ways of feeling and behaving
(Lochman et al., 2012). Children with emotional and behavioural disorders tend to perceive neutral acts by
others as antagonistic. The helper who assists should therefore work with and change the child’s perceptions and
defective way of thinking. Imparting problem-solving skills and relaxation techniques can also form part of the
treatment process. Problem-solving strategies involve several steps:
1.
2.
3.
4.
5.
A description of the setback and major objectives of the results
Creation of different resolutions
Evaluation of these explanations in achieving goals
Assortment and portrayal of the key plan
Assessment of the final results. (Southam-Gerow et al., 2010)
Feindler and associates (1986) have initiated a cognitive-behavioural program for conduct disorder that
involves gauging a person’s cause of anger, the process of self-talk to manage rage, usage of problem-solving
skills, recreation skills, and decision-making abilities. Lochman and associates (2009) proposed the Coping
Power Program, which treats both child and parent issues. The Coping Power Program addresses risk factors
for various types of conduct disorder. It deals with high-risk children, their cognitive functioning, self-regulation,
and peer and parent interactions. The Coping Power child intervention consists of about 34 sessions focusing on
anger management, skills to solve problems, and ability to repel peer influences. The core feature of the
intervention consists of 16 sessions and emphasizes support and stability in parenting. Working together with
both parent and child, this program contributes to the reduction of problematic behaviour in preadolescents and
makes the transition period easy and painless. CBT has proven to be effective in adolescents’ coping with
conduct disorders by improving their social skills, augmenting their engagements in enjoyable activities, using
recreation techniques, determining negative-irrational thoughts, forming positive counter-thoughts, and
promoting problem-solving, and conflict-resolution proficiencies (Kaufman et al., 2005).
4.1.3 Cognitive behaviour therapy and anxiety disorders & specific phobia
Cognitive behavioural therapy (CBT) has proved to be an effective intervention strategy for anxiety
disorders, and specific phobias (Hoffmann et al., 2012; Hirshfeld-Becker et al., 2010). Meta-analytic studies on
anxiety disorders indicate strong positive correlations with CBT through improved outcome, facilitated by
enhanced homework collaboration. Cognitive behaviour therapy alters the child’s inaccurate fear-creating mental
states through spoken self-talk that produces positive self-declarations. The main objective is to diffuse the effect
of the fear - inducing stimulus and develop relaxation and distracting techniques. For example, children who are
afraid of pets might be taught to tell themselves, “I am not afraid of anything – I think I can manage on my
own,” “Pets can be entertaining and relaxing – they do many entertaining things.” However, Silverman et al.
(1999, 2009) have argued that while cognitive behaviour therapy may probably be effective, it differs only
slightly from contingency management, a process that is based on the principle that behavior is a function of its
consequences, an already well-established mediation strategy for childhood phobia.
51
4.1.4 Cognitive behaviour therapy and trauma
Trauma may be treated with many of the basic interventions such as a gradual exposure, a cognitive
processing of the event, psychoeducation, and stress reduction through positive self-talk and relaxation (Murray,
Cohen, & Manarino, 2013; Cohen, Berlinger, & Mannarino, 2000). Strategies commonly used are prioritizing
safety, enhancing engagement, helping to differentiate real danger from trauma reminders, and providing
advocacy. Such intervention strategies greatly improve the mental health functioning and maintain safety to the
child and family. Research studies have shown that cognitive behaviour therapy is more successful than
nondirective supportive therapy and standard community care regardless of whether treatment is given only to
the child, only the parent or both. Cognitive behaviour therapy has been recognized to be superior to
nondirective sympathetic treatment for sexually abused children between 3-7 years old (Goenjian et al., 1997).
This form of therapy has also been found to be superior to the child-centred Rogerian therapy for improving
anxiety disorders, depressive states, and behavioural and developmental struggles connected with post-traumatic
stress disorder. Research has found cognitive behaviour therapy to be successful and useful in remedying
children with post-traumatic stress disorder when compared to the placebo group (Chemtob, Nakashima &
Carlson, 2002).
4.1.5 Critique of cognitive behaviour therapy
Despite the efficacy of cognitive behaviour therapy, empirical studies over the years have found this
strategy to be only moderately effective in treating conduct disorder and less effective than other family-based
and multisystemic treatments. In 1998, an American Psychological Association task force concluded that childfocused cognitive behaviour therapy did not meet the standards of an established treatment strategy, in contrast
to parent-focused interventions which did (Brestan & Eyberg, 1998). By focusing on the child, cognitive
behaviour therapy may not sufficiently consider family influences in the development and the maintenance of
conduct disorder (Snyder, Schrepferman, & St. Peter, 1997; Southam-Gerow et al., 2010).
Nevertheless, cognitive behaviour therapy is superior to relaxation therapy in treating all types of panic
disorders. Cognitive behaviour therapy has outclassed relaxation therapy in the areas of panic, anxiety, and
clinically proven stress disorders. The success rate has increased from 41% to 59% for cognitive behaviour over
relaxation therapy in the United States. For anxiety disorders, the increase in success rate is from 35%to 65%,
and for panic-related perceptions from 38% to 62%. Moreover, CBT participants have higher rates of clinically
significant change in panic disorders. In light of these findings there is evidence to suggest that cognitive
behaviour therapy, despite other criticisms, is an enhanced strategy to pharmacotherapy in the treatment of panic
disorders (Siev & Chambless, 2007).
That said, cognitive-behaviour psychotherapies are among the most basic mediations for major
depressive disorder (MDD) and several research studies have validated their usefulness in the management of
this disorder (Szentagotai & David, 2008)
5.
Family-based programs
Family-based interventions can be divided into two categories: those that focus on parenting and work
exclusively with the caregiver(s) and those that work with the entire family, they being Parent management
training (PMT), and Functional Family Therapy (FFT).
Parent management training (Hukkelberg & Ogden, 2013) targets preschool and elementary school
children who experience conduct problems. The theoretical framework for parent management training argues
that conduct disorder is governed by maladaptive parent-child relationships (Feldman & Kazdin, 1995; Kazdin,
1995). The therapist works with parents to modify faulty relationships with the child. This is done by relying on
principles of operant conditioning such as laying down clear-cut rules, enforcing positive or negative
reinforcements, time-outs, negotiation, and contingency contracting or imposing consequences on unwanted
behaviour (Scott, 2006). These principles endorse prosocial child behaviour and decrease antisocial or defiant
behaviour.
Family systems therapy considers treating the entire family, defined as those living together (Datchi &
Sexton, 2013). If one member of the family is diagnosed with conduct disorder, the entire family is affected or
distressed by it. Functional family therapy (FFT) (Sexton, 2011; Sexton & Alexander, 2002) consists of three
52
phases, namely: engagement and enactment, behavioural change, and generalization (Prinz & Jones, 2003).
During the first phase, the therapist meets with the family knowing that within a short period of time, the family
will demonstrate its familiar ways of behaving. The FFT clinician is vigilant to patterns of communication, and
association with limits being either too diffuse or too harsh. In the second phase, the FFT clinician begins to
interrupt these familiar patterns and restores power and authority to the decision-making subsystem. In the third
phase, the family members are taught to apply their new knowledge by anticipating problems, practicing, and
checking themselves from deteriorating into long-standing, and familiar ways of conducting themselves with
others.
The advantage of Functional Family Therapy (FFT) is its short-term focus consisting of 6 to 12
sessions. Two disadvantages are the difficulty of engaging the entire family system and the lack of helpers
sufficiently trained to work with the whole family. Over the years, family counsellors have become known for
their direct and sometimes belligerent style, which is often at odds with the traditional training given to
individuals. Even though research evaluating Functional Family Therapy is rather meagre, a number of studies,
however, have shown that FFT can be applicable in diminishing recidivism rates among adolescents with
delinquent histories and improving the functioning of those with conduct problems (Alexander, Robbins, &
Sexton, 2000; Friedman, 1989).
6.
Psychopharmacological interventions
This method involves the use of specific drugs to treat the various disorders. For example, for conduct
disorder, the most widely prescribed medications are stimulants, the most popular one being Ritalin. Since
conduct disorder is closely comorbid with Attention Deficit Hyper Disorder (ADHD), the use of Ritalin has been
effective in easing conduct problems in children with both these types of disorders (Nevels, Dehon, Alexander,
& Gontkovsky, 2010; Conner, Glatt, Lopez, Jackson, & Maloni, 2002). Ritalin is an effective medication to
control adverse symptoms such as distraction and agitation for almost 70% of persons detected with ADHD.
The initial dose followed by two more needs to be administered and the effects carefully monitored. Concerta is
also used to treat children and teens with ADHD and is designed to address the need for long-term outcome
(Ipser & Stein, 2007; Greenhill, Halperin, & Abikoff, 1999).
Zoloft and Xanax, and SSRIs are used moderately to improve the overall status of the child
experiencing anxiety disorders, posttramautic stress disorder, generalized anxiety disorder, and obsessive
compulsive disorders. In cases of comorbidity with obsessive-compulsive disorder, the use of a selective
serotonin reuptake inhibitor (SSRI) is generally considered. For bulimia, SSRIs and antidepressants (Prozac)
may be used (Schneck et al, 2008; Preston et al., 2006).
In cases of depressive and bipolar disorders, the usual pharmacological treatments are SSRIs, Trycyclic
antidepressants (TCAs), and monamine oxidase inhibitors (MAOIs). SSRIs need to be used with caution as they
may increase the rate of suicides. More recently, Risperdal has been known to be an antipsychotic that is FDA
(Food and Drug Administration) approved and used for autism spectrum disorder. As well, SSRIs such as
Prozac, Zoloft, Paxil, and Remeron have all been used in the treatment of autism. It must be remembered that
medications, in general are only effective in reducing symptoms of any of the above disorders. If combined with
other psychosocial treatments, the rate of progress and evolution is much higher (Sallee et al., 2009; Posey et al.,
2008; Kawatch et al., 2005; Swanson et al, 2008).
7.
Multisystemic treatment
A multisystemic approach is the most effective method in the treatment of emotional and behavioural
disorders in children and adolescents. It is an intensive, short-term, family and community-based treatment
approach that focuses on the individual, peer-group, school, and community influences that set off problematic
externalizing behaviour in young people (Weiss et al., 2013; Henggeler, 2011; Ronan & Curtis, 2008;
Henggeler & Borduin, 1990). This approach explicitly sanctions parents and significant others to contribute to
reducing the challenging behaviours. The program utilizes therapists available to the family round the clock for a
period of 4-6 months to restructure a young person’s environment towards prosocial development.
Several behavioural maladies are simply indicators of years of physical, mental or emotional abuse,
unsuccessful parenting, and irrational family structures. The distressed children growing up in these
circumstances may assimilate and integrate the damaging and disparaging actions of their guardians or they may
develop mechanisms that depict antisocial or troublesome behaviours as survival methods. These objectionable
behaviours are then carried into the classroom, with the result that the teacher is repeatedly replaced for the
parent. In such cases, teachers can implement behavioural mediations that consider an affirmative reinforcement
system to help diminish the undesired behaviours while supporting and boosting more constructive ones.
53
However, it is dangerous to assume that children learn by a gradual, often instinctive process of adaptation or
adjustment. It is therefore, necessary that the teacher impart these aids of pro-social, helpful and valuable ways
of considering and approaching a problem. Thus, for students who engage in insolent, violent, or vicious
behaviours, teaching some sort of cognitive-behavioural response is highly advocated. An intervention that is
solely behavioural is discrete trial training, an approach that highlights attention-span, motivation, stimulus
control, observational learning, communication, and perspective-taking (Ward-Horner, & Sturmey, 2008).
More recently, multisystemic therapy applied to conduct disorder has shown a great deal of
achievement. It has demonstrated that family cohesion and interventions are relevant, and pertinent. However,
the family is only one of the many milieus in which the child situates himself or herself (Saldana & Henggeler,
2006). These other arrangements include peers, school, and the community at large. Research has shown that not
only family relations, but attachment to deviant peers, troubles in school, and neighbourhood/community factors
are strong contributors to delinquency (Henggeler, 1991; Henry, Tolan, & Gorman-Smith, 2001; Le Blanc &
Kaspy, 1998; Paschall & Hubbard, 1998). These studies suggest that successful treatment must include a
multisystemic approach.
Multisystemic therapy deals with multiple factors related to emotional and behavioural disorders. At the
family level, it employs an aspect form of family functioning therapy by investing parents with skills and assets
to deal with problems that come up in raising youth. It fosters increased family structure and cohesion involving
intensive strategic family therapy, structural family therapy, and behavioural parent training. At the peer level,
the intervention attempts to diminish associations with deviant peers and replaces those relationships with
prosocial peers by facilitating membership in organized athletics, after-school activities, and church youth
groups (Borduin, Schaeffer, & Ronis, 2003). At the school level, the therapeutic intervention supervises school
performance by freely communicating with parents and teachers and structures time to go over homework and
other school-related activities. A collaborative relationship between parent and school is developed and
academic efforts are promoted. If genetic and biological factors are built-in, the multisystemic therapy makes use
of psychopharmacology as well. Multisytemic therapy is, therefore, broad-based, and suitable to deal with all
factors contributing to any type of conduct disorder. For example, a parent’s stress due to unemployment would
also be addressed by the therapist.
A number of multisystemic therapeutic programs operate nationwide, including Fast Track and project
LIFT. Fast Track pre-emptive strategy provides two levels of interventions for parents and children during the
elementary school years (Conduct Problems Prevention Research Group, 2010). At-risk children demonstrating
early conduct problems go through a series of interventions to improve their social skills, and academic
performance. Individualized academic tutoring is delivered to such children and weekly support classes are
provided to parents. These interventions are believed to reduce risk factors and promote protective qualities in
children who are prone to conduct problems.
LIFT refers to Linking the Interests of Families and Teachers and is a program designed to promote the
positive development of at-risk elementary school children and adolescents. The program consists of a 10-week
training to improve participants’ social skills and enhances parenting practices. It also improves confidence, selfefficacy, and resourcefulness in children (Eddy, Reid, & Fetrow, 2000). A comparative study of children
receiving the LIFT intervention with those in the control group revealed that the program significantly delayed
the first time experimenting with illicit drugs, marijuana use, and police arrest (Ialongo et al., 2001).
Validated by research, multisystemic therapy has demonstrated to be a proficient method to deal with
unmanageable, and disruptive behaviour (Letourneau et al., 2009; Ogden & Hallday-Boykins, 2004; Schaeffer &
Borduin, 2005), violent and chronic offenses (Tighe et al., 2012; Henggeler, Melton, & Smith, 1992; Henggeler,
Pickrel & Brondini, 1999), substance use and abuse (Brown, Henggeler, Schoenwald, Brondino, & Pickrel,
1999; Henggeler et al., 1999; Henggeler, 1991) and sexual offenses (Fortune & Lambie, 2006; Borduin,
Henggler, Blaske, & Stein, 1990; Borduin & Schaeffer, 2001). In spite of documented success, however,
multisystemic therapy is not always the favoured method of remedy for conduct disorder (Sundell et al., 2008).
One disadvantage is that multisystemic therapy is that it is enormously time-consuming. Another practical
concern is the time spent by a provider on settling insurance reimbursement which makes it arduous for some
clinics and programs to promote or perform this type of therapy.
Conclusion
This inquiry has addressed various effective treatment strategies for emotional and behavioural
disorders in children and adolescents. From secondary sources, the analysis looks critically at four major types of
interventions, namely, cognitive behaviour therapy, family-based programs, pharmacological interventions, and
multyststemic therapy. It may be concluded that no one form of treatment is appropriate or the right one for any
of the emotional and behavioural disorders. A combination of one or two or all of the intervention strategies may
be fitting to individual cases. What is important is that precise judgment must be used in selecting any of the
above intervention strategies for each child or adolescent experiencing an emotional or behavioural disorder
54
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Author Index
Alonim H., 1
Bateman H., 5
Bolsoni-Silva A.T., 11
Borsci S., 25
Cordella B., 15
Cosentin C., 43
Duncham H., 5
Federici S., 25, 31
Ferreira P.P., 11
Fontana F., 43
Grasso M., 15
Greco F., 15
Maxwell L., 5
Mele M.L., 25, 31
Meloni F., 31
Panayiotopoulos C., 37
Pavlakis A., 37
Pruneti C., 43
Samuel E., 49
© Medimond
1

Publication of the Proceedings of the 16th APPAC 2011

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